Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES ·::1:-'.NTERS FORM DICARE & MEDICAID SERVICES · .,,,EMENT OF DEFICIENCIES AND PLAN OF CORRECTION O B 0. 938-0391 (lC2) MULTIPLE CONSmUCTlON A.BUILDING _ _ _ _ _ __ (X1) PROVIDERISUPPUER/CLIA IDENTIFICATION NUMEIER; COMPLETED c 03/19/2014 STREET ADDRESS. CITY, STATE. ZIP CODE RIVER POINT BEHAVIORAL HEALTH 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4)1D PREFIX TAG (X3) DATE SURVEY B. WING, _ _ _ _ _ _ _ __ 104016 NAI.£ OF PROVIDER OR SUPPLIER 04/07/2014 FORM APPROVED B 000 INITIAL COMMENTS An unannounced complaint survey was , conducted by federal consulting surveyors In conjunction with Florida state surveyors from I· March 17-19, 2014. The census at the time of this survey was 99 patients; the sample of active patients was 8. B 103 482.61 SPEC MEDICAL RECORD REQS FOR PSYCH HOSPITALS The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished senrices in the institution. I This Condition is not met as evidenced by: · Based on observation, record review, and interview the facility failed to: (XS) COMPLETION PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG DATE 8000 ! Submission of this plan of correction is not an admission by the hospital that the citations and their underlying findings or observations are correct or that the hospital violated the rules. I 1The hospital reviewed and revised pertinent 105-01-2014 8103 policies and processes, provided training to hospital staff and physicians, and implemented 1 monitoring to confirm that medical record j documentation is completed in accordance with / policy and the rules. The hospital also disagrees with some of the statements in some of the citations. As directed by CMS State Operations Manual section 30268, the hospital offers the basis for its disagreement under the applicable tags. Please see the detailed responses to B 118, B 125 I, B 12511, and B 125 Ill. I. Ensure that physicians participated in the collaborative development of the treatment plans for 4 active patients who were added to the sample in order to evaluate the treatment planning process. In addlUon, 6 of 8 sample patients (A20, A24, 82, 828, C6, and C19) had initial MTPs that did not have a physician signature. The space on the MTP fonn where the physician was to sign contained the statement, "Physician Approval of Treatment Plan .a Failure of the physician to direct the treatment team in the development of individualized patient goals and needed therapeutic Interventions places lhe responsibility for patient treatment on the other j team members potentially depriving the patient of needed treatment and possibly increasing the length of stay. (Refer to 8118) I III. Ensure an adequate assessment of the TITLE Any defidency statement ending with an est k rl danales • de · ncy which the lnstib.llion m11y be sed from co11ectln9 PIIJVldlng it is delerml that other s11feguards pR>Vld11 sulflcienl protection lo Iha paUents. (See inalnlCllons.) Except for nursing homes. the findings sl11led above ara disdosable 90 days roftowing the dale or survey whether or not a plan of correclian is provided. For nulling homes, the above findings and plans of correction are disclosable 14 days following Iha date lhes11 documenls are lllllde available IO the facifty. Ir deficiencies are cllad, an approved plan of correction Is requisite ro continued progrem participation. FORM CMS-2587(02-99) Previous Versions Obsalele WSXR11 II oonUnualion llheel Page 1 or 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ ex 1) PROVIOER/SUPPLIERJCLIA IDENTIFICATION NUMBER: c B. \II.ING _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER (X3) DATE SURVEY COMPLETED 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH 6300 BEACH BLVD JACKSONVILLE, FL 32216 (X4)1D PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED av FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 103 Continued From page 1 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE B 103 readiness for discharge for 1 of 8 sample patients (C25). Being hospitalized beyond the time needed to reach optimal benefits results in lack of opportunity for patients' mental health and psychosocial improvement through transitional community services and community integration. (Refer to 8125 I) Ill. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for 1 of B active patients (A24). This patient spent much of the time in bed or walking idly in the hallway missing assigned programming. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge. (Refer to 8125 II) IV. Assess and treat the medical problems of 1 of 8 sample patients (C25), in order to identify potentially treatable medical etiologies of mental status changes and identify potential concurrent medical illnesses. Failure to address medical issues and obtain a correct diagnosis and treatment results in a potential risk to patients' lives/health and prevents patients from achieving an optimal level of functioning. (Refer to 8125 Ill) B 108 482.61 (a)(4) DEVELOPMENT OF ASSESSMENT/DIAGNOSTIC DATA The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history. This Standard is not met as evidenced by: Based on record review and interview, the facilfty FORM CMS-2567(02-99) Previous versions Obsolete 8108 The Director of Social Services and Social 04-18-2014 Services Manager reviewed and revised the policy "Comprehensive Needs Assessment" to include a requirement for an evaluation of the patient's social functioning level to be utilized in the development of an effective and meaningful treatment plan and discharge plan. The policy was also reviewed and reaffirmed to have the correct required time frame for completion of psychosocial assessments. (Attachment 8) WSXR11 If canllnuallnn sheel Page 2 ol 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER RIVER POINT BEHAVIORAL HEALTH (X4)10 PREFIX TAG 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 108 Continued From page 2 failed to provide social work assessments that included an evaluation of the current baseline social functioning for 5 of 8 sample patients (A24, 82, CS, CB, and C19). As a result, the treatment teams did not have an assessment of current baseline social functioning for these patients from which treatment Interventions and discharge plans could be formulated. Findings include: A. Record Review 1. Patient A24 The "Psychosocial Assessment" for Patient A24 dated 3/5/14 stated that the "Clinical Formulation" was "Pt [patient] is a 31 yr [year] old African American [fe/male] single who was admitted on 8.A. [Baker Act] for psychosis. Pt denies any and all fonn of abuse. Pt completed high school." This psychosocial assessment did not contain an evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan. 2. Patient 82 The "Psychosocial Assessment" for Patient 82 dated 3/12/14 stated that the "Clinical Formulation" was "Pt [patient] admitted endorsing thoughts of suicide seeing things others don't see. Pt has a hx [history] of HTN [hypertension] and Hep [hepatitis] B. Pt reports enjoying fishing. Pt has some college [with] not (sic) intent of continuing currently. Pt does not currently have any labs to date." The "Anticipated social worker role(s) in treatment" was "none." This psychosocial assessment did not contain an evaluation of social functioning level to utilize in FORM CMS·2567(D2·99) Previous Versions Obsolete ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE 8 108 The Director of Social Services and Social 04-23-2014 Services Manager also reviewed and is revising he Psychosocial Assessment form to more clearly define the requirement for inclusion of an evaluation of social functioning level to be utilized in development of an effective and meaningful treatment plan and discharge plan. !The Director of Social Services and the Social 04-30-2014 !Services Manager provided training to all social workers and therapists in the department egarding the revised policy and form. Training was provided in the Social Services meeting land in individual training for those unable to attend the meeting and included review of the equirements for: The psychosocial assessment to be ~ompleted within 48 hours of admission Inclusion of an evaluation of social Functioning level in the psychosocial summary isection Utilization of the social functioning level in kJevelopment of treatment and discharge plans. "-lnderstanding and competency were confirmed i:>y individual review by the Social Services Manager of a completed assessment of each istaff member post-training. The Director of !Social Services tracked attendance to confirm hat all social workers and therapists received he training. rThe Staff Development Director and HR Director have modified the orientation program Jar social services/therapy staff to include greater emphasis on the elements of the psychosocial assessment including an evaluation of social functioning level. 04-30-2014 The Social Services Manager/designee is using a newly developed audit tool to monitor 100% of Psychosocial Assessments weekly for a period of 90 days to confirm that all Psychosocial Assessments are completed in a timely fashion and include an evaluation of social functioning Monitoring beginning 5-1-14 and ongoing WSXR11 Ir conUnuatlon sheel Page 3 or 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: A. BUILDING _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CllY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 108 Continued From page 3 developing an effective and meaningful treatment plan. 3. Patient C5 The "Psychosocial Assessment" for Patient CS dated 3/8/14 stated that the "Clinical Formulation" was "This is a repeat admission to RPBH [River Point Behavioral Health]. [S/he] was BA [Baker Act] due to delusional thoughts & experiencing both NH [auditory hallucinations] & V/H [visual hallucinations]. The pt. is unable to fully advise of her reasons for admission to RPBH. [S/he] believes ppl [people) have been abusing her, but this has been found to be unsubstantiated. The pt. advised the attending physician that [s/he] has a long hx [history] alcohol induced blackouts, although the pt has been living in institutions for [approximately] 10 years. Pt. enjoys art. Diagnostics [multiple abnormal laboratory values]." This psychosocial assessment did not contain an evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan. ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION OATE B 108 level. (Attachment A) Following the initial review, if compliance has been achieved at 90%, a random sample of 30% of psychosocial assessments will be reviewed each week for another six months. Staff not in compliance will receive retraining by the Social Services Manager and/or disciplinary action as appropriate. The Social Services Manager is responsible for aggregating the data and reporting it monthly to the Quality Committee, Medical Executive Committee, and quarterly to the Governing Body. 4. A review of the medical records on 3/17/14 for the following patients (dates of admission In parentheses) contained no social work assessments to determine the current social functioning of the patient: Patient CS (3110/14) and Patient C19 (3/13/14). B. Staff Interview During an intervlew on 3/18/14 at 9:40 a.m. with the Director of Behavioral Services (supervisor of social services), she acknowledged that the psychosocial assessments for Patients C6 and C19 were not completed at the time of review on 3/17/19. FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 II conllnuatlon sheel Page 4 of 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (X 1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: A. BUILDING _ _ _ _ _ _ __ (XJ) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CllY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 8300 BEACH BLVD JACKSONVILLE, FL 32218 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 108 Continued From page 4 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE B 108 C. Policy Review A review of the facility policy "Comprehensive Needs Assessment" "effective 12199, last reviewed 2/2014," presented as the current policy, stated the "Licensed Therapist. ..obtains Psychosocial History from the patient, family and/or significant others within seventy two (72) hours of admission, signed and dated." B 110 482.61(b) PSYCHIATRIC EVALUATION Each patient must receive a psychiatric evaluation. This Standard is not met as evidenced by: Based on record review and interview, the facility failed to ensure that 2 of 8 active sample patients (CS and C19) received a psychiatric evaluation containing sufficient information to justify diagnoses and treatment. For Patient CS, the psychiatric evaluation failed to document a developmental disability noted by other staff during hospitalization and from history. In addition, a diagnosis of "alcohol abuse/dependence" was listed and treatment for alcohol withdrawal was ordered and continued despite evidence from the community that the patient did not consume alcohol. For Patient C19, the psychiatric evaluation failed to document cognitive problems noted by other staff during hospitalization and from history. This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate master treatment plan. Findings include: A. Record review FORM CMS-2567(02·99) Previous Versions Obsolete B 110 The Medical Director and Pl Director provided 04-22-2014 retraining to all psychiatrists on the requirements for completion of thorough, individualized psychiatric evaluations of all patients to support treatment planning and appropriate interventions. Training was provided during the Medical Executive Committee meetings on 3/27/14, 4/4/14, and 4/18/14. Any psychiatrist not in attendance received individual training from the Medical Director. Training completion was tracked by the Pl Director to confirm that all psychiatrists received the training. Each physician·signed a validation statement of understanding of training and requirements. Training included review of the need to: Identify any developmental/cognitive disorders Review assessments completed by other staff as additional resources for the psychiatric evaluation and treatment plan Provide sufficient information to justify all diagnoses and treatment provided Address all diagnoses/problems in the treatment plan The Medical Director and designees are using a newly developed audit tool to review 100% of psychiatric evaluations each week for a period of 90 days to confirm that the 1) psychiatric evaluations contain sufficient information to justify diagnosis and treatment and are consistent with other assessments and oatient WSXR11 Monitoring beginning 04-21-2014 and ongoing If conllnualion sheet Pege 5 or 46 Printed: STATEMEt.T OF DEFICIENCIES AND PLAN OF CORRECTION 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIOER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH 6300 BEACH BLVD JACKSONVILLE, FL 32216 {X4)1D PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 110 Continued From page 5 1. Patient C6 a. Patient C6 was a 32 year-old admitted to the "older adult unit" on 3/10/14 because of "basically wanting to kill [him/herselij with a knife." The "Psychiatric Evaluation" dated 3/11/14 stated "[S/he stated that [s/he) drinks until [s/he] blacks out. At the current time, [s/he] probably needs to be on Librium detoxification protocol." "Developmental history" was blank. The "Mental Status Examination" stated "cognition is limited. Concrete thinking noted." Patient C6 was reportedly had "registration and recent memory are intact for recall of 3 unrelated objects immediately and in 5 minutes." The "Estimate of intelligence" was "Intelligence appears average, based on the client's level of formal and self-education, counting, calculation and general fund of knowledge." No psychotic symptoms were noted in this evaluation. The only diagnoses were "Schizoaffective disorder, currently depressed, severe intensity, with mood-incongruent psychotic features" and "alcohol abuse/dependence." 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 8 110 history; and 2) that the treatment plans for each patient reflect the accurate diagnoses of the patient. (Attachment C) Following the initial review, if there is 90% compliance with meeting the audit criteria, a random sample of 30% of psychiatric evaluations and treatment plans will be reviewed weekly for another six months. Psychiatrists not in compliance will receive retraining by the Medical Director and referral to the Medical Executive Committee for focused practice evaluation if the psychiatrist has repeated noncompliance after retraining by the Medical Director. The Medical Director and Director of Pl report aggregated data from these audits monthly to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. b. The "Second Opinion Psychiatric Evaluation" dated 3/12114 stated that Patient C6 "appears to have a developmental disability, as well as a diagnosis of psychosis." This opinion stated "[slhe) appears to have learning disabilities" and "[his/her] cognitive functioning appears to be consistent with borderline intelligence/mild mental retardation." Diagnoses included "rule out borderline intelligence/mild mental retardation." c. The "Psychosocial Assessment" dated 3/17/14 at 4:25 p.m. ("replacement from 3/12114'1 stated that Patient C6's "Developmental History" included "special ed [education] classes" and FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 If conllnualian shoel Page 6 or 46 Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STAlE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 04/04/2014 FORM APPROVED 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY DR LSC IDENTIFYING INFORMATION) B 110 Continued From page 6 "developmentally disabled." The assessment stated that Patient C6 "resides in a group home for residents w/ [with] cognitive deficits .... [S/he] told the Dr. [doctor] [s/he] drinks alcohol off & on and that [s/he] drinks until [s/he) blacks out.... [Her/his] group home caregiver reports that the pt. [patient] does NOT drink ETCH (alcohoO." 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS} C:OMPLETION OATE B 110 d. The "Physician Orders" dated 3/10/14 at 10:00 a.m. stated "Librium 25 mg [milligrams] po (orally] lid [three times per day] prn [as needed] for W/D [withdrawaij." A review of the Medication Administration Record on 3/17/18 indicated that the order was in effect at that time. e. The "Master Treatment Plan" (MTP) dated 3/10/14 and reviewed on 3/18114 at 11:00 a.m. listed the diagnoses as "Schizoaffective Disorder, depressed, severe" and "Alcohol Dependence." Axis II diagnoses were "deferred." There were no problems, goals, or interventions that considered Patient C6 • s reported developmental disability. 2. Patient C19 a. Patient C19 was an 81 year-old admitted 3/13/14 "after [s/he] threw [her/his] food at [her/his] [spouse]." The "Psychiatric Evaluation" dated 3/14/14 stated that Patient C19 "believes that [s/he] Is currently in Michigan" and [her/his] chief complaint was "I can't wait until the snow stops." "The patient is a very poor historian" and "it is uncertain if the patient Is cognltfvely Intact to answer questions like that [substance abuse history]." ''The patient is alert and oriented times zero." The only diagnosis was "psychosis, NOS." b. The "Consultation" assessment for Patient C19 by the medical provider on 3/13/14 stated "[s/he FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 II contlnualion sheel Page 7 or 46 Printed: STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION 04/04/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300. BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 110 Continued From page 7 appears demented" and that medications included Aricept and Namenda. The "Assessment/Plan" included "Alzheimer's disease." ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 110 c. The MPT dated 3/13/14 stated the only diagnosis was "Psychosis, NOS." There were no problems, goals, or interventions that considered Patient C6's reported dementia. 8. Staff Interview 1. During an interview with MD 4, attending psychiatrist for Patient C6, he stated that Patient C6's diagnosis was "schizophrenia." He stated that the primary symptom was "delusions" although he was not able to indicate where the type of delusion was documented in the medical record and stated he could not remember. He stated that he believed that Patient C6 was "self-medicating" with alcohol and might benefit from attendance at Alcoholic Anonymous meetings. 2. During an interview with the Medical Director and Director of Behavioral Services on 3/19/14 at 12:35 p.m., the Medical Director stated that "many times patients carry their [historicaij diagnosis rather than change them [diagnoses]." ''They accept the diagnosis from the outside provider." He acknowledged that no diagnosis reflecting the developmental disability of Patient C6 was documented in the Psychiatric Evaluation for Patient C6. The Medical Director acknowledged that no diagnosis reflecting Patient C19's cognitive disorder was documented in the Psychiatric Evaluation for Patient c1g. The Medical Director stated "until the discharge summary is done, it doesn't require a diagnosis." B 118 482.61(c)(1) TREATMENT PLAN FORM CMS-2567(02-99} Previous Versions Obsolete 8 118 The Medical Director, Director of Pl, Chief WSXR11 03-27-2014 Ir conlinualion sheer Page B or 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVlDER/SUPPUERJCLIA IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X4)1D PREFIX TAG 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 8 Each patient must have an Individual comprehensive treatment plan. This Standard is not met as evidenced by: Based on record review, observation and interview the facility failed to ensure that physicians participated in the collaborative development of the treatment plans for ,4 active patients who were added to the sample in order to evaluate the treatment planning process. In addition, 6 of 8 sample patients (A20, A2-4, 82, 828, CB, and C19) had initial MTPs lhat did not have a physician signature. The space on the MTP form where the physician was to sign contained the statement, "Physician Approval of Treatment Plan." Failure of the physician to direct the treatment team in the development of Individualized patient goals and needed therapeutic interventions places the responsibility for patient treatment on the other team members potentially depriving the patient of needed treatment and possibly increasing the length of stay. Findings Include: A. Record Review 1. Patient A20's initial MTP dated 3/11/14 did not have a psychiatrist signature to Indicate physician direction or participation in the establishment of an individualized treatment plan. 2. PatientA24's initial MTP dated 3/-411-4 did not have a psychiatrist signature to indicate physician direction or participation in the establishment of an individualized treatment plan. FORM CMS-2567(02-99) Previous Versions Obsolete c B. WING _ _ _ _ _ _ _ __ 104016 RIVER POINT BEHAVIORAL HEALTH (X3) DATE SURVEY COMPLETED 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (KSJ COMPLETION DATE B 118 Nursing Officer, and Director of Social Services reviewed and revised the policy on "Treatment Planning Process" to clarify the psychiatrist's role in leading the treatment team, specifying ~hat, "The Physician is responsible to lead the treatment team and works with the other members of the team, to ensure all components of the Treatment Planning process are complete" and " ... .team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. At minimum, the clinical staff ncluding the Physician, Therapist/Social Worker, and RN. Ultimate responsibility for the development and implementation of the reatment plan shall rest with the physician." (Attachment E) rrhe revised policy "Treatment Planning Process" was reviewed and approved by the Medical Executive Committee and the (;overning Body. D4-04-2014 eased on input from the medical staff, the 04-14-2014 Director of Pl, CNO and Director of Social Services developed a revised process and schedule for treatment planning meetings to assure the physicians' availability to participate 'n the treatment planning process. With the new schedule, each attending psychiatrist has two treatment planning meetings per week with he RN and Therapy/Social Services staff rotating in and out of the meeting to allow the psychiatrist to review patients from all units in ~he same meeting. Coordination of the meetings s done by the Program Directors of each unit who maintain a schedule of all patients needing initial treatment plans or treatment plan reviews. (Attachment D) The Medical Director, CEO, and Director of Pl provided training to all attending psychiatrists on: The revised Treatment Planning Process policy WSXR11 04-04-2014 II conllnualion sheel Page 9 or 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) CATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BV FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 9 3. Patient B2's initial MTP dated 3/12114 did not have a psychiatrist signature to indicate physician direction or participation in the establishment of an individualized treatment plan. 4. Patient B28's initial MTP dated 3/10/14 did not have a psychiatrist signature to indicate physician direction or participation in the establishment of an individualized treatment plan. 5. Patient CB's initial MTP dated 3/10/14 did not have a psychiatrist signature to indicate physician direction or participation in the establishment of an individualized treatment plan. 6. Patient C19's initial MTP dated 3/13/14 did not have a psychiatrist signature to indicate physician direction or participation in establishment of an individualized treatment plan. B. Observations 1. During Treatment Team Meeting on 3/18/14 at 1O:OO a.m. on the North Wing, Patient E3 was presented for his/her Initial MTP. The team .meeting was directed by Clinical Manager 1 who asked the patient about his/her depression and chronic headaches. RN2 and Therapisl2 were in attendance. Patient E3's physician, MD3 was not in attendance nor was s/he mentioned during the team meeting. 2. During Treatment Team Meeting on 3/18/14 at 10:15 a.m. on the North Wing, Patient E2 was presented for his/her MTP update/review. The team meeting was directed by Clinical Manager 1 who questioned the patient about his/her depression and suicidal thoughts. RN2 and Therapist 2 were in attendance. Patient E2's physician MD2 was not in attendance nor was FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG B 118 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE The revised treatment plan meeting schedule Expectations for psychiatrists to attend all of their treatment team meetings and participate as leaders of the team. The CNO and Director of Social Services b4-30-2014 provided training in group meetings to all RNs, Therapists/Social Workers, and Activities Therapy staff on the revised "Treatment Planning Process" policy and expectations for adherence to development and documentation of individualized treatment plans for all patients, the elements of the revised Treatment Planning Process, the revised treatment plan meeting schedule, and the expectations for psychiatrists to attend all their treatment team meetings and participate as leaders of the team. Attendance at training was tracked by the HR Director who used employee lists and sign in sheets to validate attendance. Any staff member not receiving training in group sessions was suspended pending receipt of individual training. Understanding of training was validated by post-test. Attendance by the physician at all treatment team meetings is maintained by the Unit Program Directors. (Attachment D) Any non-compliance with attendance at a scheduled treatment team meeting is reported that day to the Medical Director and CEO for immediate follow-up with the physician. Repeated non-compliance will be referred to the Medical Executive Committee for disciplinary action. Aggregated data on physician attendance is reported by the Director of Behavioral/Social Services monthly to the Medical Executive Committee and quarterly to the Governing Body. Treatment team attendance is also maintained as part of the Ongoing Professional Practice Profiles for each psychiatrist, and that information is utilized in the reappointment process. WSXR11 Monitoring beginning 04-14-2014 & ongoing If conUnuallon shee1 Page 10 al 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER; (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CllY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 11 B Continued From page 10 s/he mentioned during the team meeting. 3. During Treatment Team Meeting on 3/18/14 at 10:40 a.m. on the Emergency Stabilization Unit, Patient E1 was presented for his/her Initial MTP. The team meeting was directed by Clinical Manager 2. When Patient E1 asked how long he/she would be there, Clinical Manager 2 stated, "We are your treatment team and Inform you of your rights but your doctor decide how long you will be here." RN 1 and Therapist1 were in attendance. Patient E1's physician MD2 was not in attendance. C. Interviews 1. In interview on 3/18/14 at 10:30 a.m., Clinical Manager 1 when asked if MD2 attended treatment team meetings answered "No" According to the Census Data sheet dated 3118/14, MD2 had 5 patients on Clinical Manager 1's unit. When asked if MD6 attended treatment team meetings Clinical Manager 1 stated, "[He/She] is new. [He/She] has been here once or twice." (Treatment team meetings were held Monday-Friday from 10:00-11:00 a.m.) According to the Census Data sheet dated 3/18/14 MD6 had 4 patients on Clinical Manager 1's unit. 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS.REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 118 As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing that the purported failure of a physician to attend a treatment team meeting or to sign the MTP means the physicians are not directing patients' care: On the contrary, it is well-documented that physicians do direct the treatment team and patients' care, including with respect to the development of individualized patient goals and any needed therapeutic interventions. Medical records document that physicians evaluate their patients, see patients at least every weekday, and write progress notes and orders specific to each patient. Physicians discuss each of their patients' care with nursing and clinical staff when they are on the unit and accordingly direct such staff overall on patients' care. Physicians have also had a long practice of rounding at least weekly and discussing patients and treatment with the clinical staff. While the development of individualized comprehensive treatment plans are and should be the product of collaboration among all members of the treatment teams, the hospital's physicians lead and direct that process. 2. In Interview on 3/18/14 at 10:50 a.m., Clinical Manager 2, when asked if MD2 attended treatment team meetings, answered "Well, no." According to the Census Data sheet dated 3/18/14, MD2 had 10 patients on Clinical Manager 2's unit. When asked if MD6 attended treatment team meetings, Clinical Manager 2 answered "[He/She] has only been here about a month." Clinical Manager 2 further stated that MD6 had never attended a treatment team meeting on his/her unit. According to the Census FORM CMS-2567(02-99) Previous VerslDI\S Obsolete WSXR11 II continuallon •heel Page 11 ol 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (X1) PROVIOER/SUPPUERICLIA IDENTIFICATION NUMBER: A. BUILDING _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH {X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 11 Data sheet, dated 3/18/14 MDB had one patient on Clinical Manager 2's unit. 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 118 3. In Interview on 3/18114 at 11: 00 a.m., Patient 828 stated that his/her physician, MD2, came to see her at night after B p.m. VVhen asked if MD2 ever came during the day, Patient 828 replied "no." 4. In Interview on 3/18/14 at 2:45 p.m., Clinical Manager 1, when asked if MD6 had been in attendance at Patient E4's Initial MTP on 3117/14, answered "no." When asked if MD2 came to the hospital during the day, Clinical Manager 1 sated that MD2 worked somewhere else during the day and came to the hospital to see patients late at night between 8:00-10:00 p.m. 8 121 482.61(c)(1)(ii) TREATMENT PLAN The written plan must include short-tenn and long range goals. This Standard is not met as evidenced by: Based on record review and inteiview, the facility failed to provide Master Treatment Plans that included short-term goals stated in measureable, patient focused terms for 8 of 8 active sample patients (A20, A24, 82, 828, 838, C5, CB, and C19). In addition, 5 of B active sample patients (A20, 82, 828, 838 and CB) had unmeasurable goals that required patients to report to staff thoughts of harm to self or others, placing the responsibility of treatment on the patient. These deficient practices hamper the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of staff interventions based on changes in patient behaviors. FORM CMS-2567(02-99) Previous Versions Obsolete 8121 The Medical Director, Director of Pl, CNO, and 04-18-2014 the Director of Social Services reviewed and revised the policy "Treatment Planning Process" to clarify expectations in the following areas: All long term and short term goals must be stated in measurable, behavioral, observable terms Individualized treatment interventions with a specific purpose and focus are to be clearly described so that treatment interventions are more than just generic monitoring or routine clinical functions Identification of the specific individual(s) responsible for the intervention must include the name and credentials/discipline. Staff need to identify alternative treatment interventions for patients unable or unwilling to attend regular programming. (Attachment E) The revised policy "Treatment Planning Process" was reviewed and approved by the Medical Executive Committee and the Governing Body. WSXR11 04-18-2014 II continuallon sheet Page 12 or 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG B 121 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 Findings include: A. Record Review 1. PatientA20 was admitted on 3/11/14. The MTP dated 3/11/14, for the identified problem "Psychotic Behaviors/Out of Contact with Reality" had the short-term goal, "Patient wlll demonstrate decreased reaction to internal stimuli 3 times per day." For the problem "Depressed Mood with Suicidality" the short-term goals were "Patient will report any suicidal thoughts/impulses/urges to staff before acting on them" and "Patient will report any 'command' hallucinations to staff before acting on them." 2. Patient A24 was admitted on 3/4/14. The MTP dated 3/4/14, for the problem "Psychotic Behaviors/Out of Contact with Reality" had the short-term goal, " Patient will demonstrate decreased hallucinatory episodes 1 times [sic] per day." 3. Patient 82 was admitted on 3/11/14. The MTP dated 3/12/14, for the problem "Depressed Mood with Suicidality'' had the short-term goals "Patient will report any suicidal thoughts/Impulses/urges to staff before acting on them" and "Patient will demonstrate Increased interest in activities through full and active participation in groups/programs for (blank space) days." 4. Patient 828 was admitted on 3/10/14. The MTP dated 3/10/14, for the problem "Depressed Mood with Suicidality" had the short term goals "Patient will report any suicidal thoughts/impulses/urges to staff before acting on them" and "Patient will seek out a staff member daily to check-in about suicidal ideation." FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG 1xs1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CDl,IPLETIDN DATE 8121 The CNO and Director of Social Services 04-30-2014 provided training in group meetings to all RNs, Therapists/Social Workers, and Activities Therapy staff on the revised "Treatment Planning Process" policy and expectations for adherence to development and documentation of individualized treatment plans for all patients Which include the elements of: All long term and short term goals stated in measurable, behavioral, observable terms Individualized treatment interventions with a specific purpose and focus clearly described so that treatment interventions are more than uust generic monitoring or routine clinical functions Identification of the specific individual(s) responsible for the intervention including the name and credentials/discipline. Identification of alternative treatment interventions for patients unable or unwilling to !attend regular programming. !Attendance at training was tracked by the HR Director who used employee lists and sign in sheets to validate attendance. Any staff members not receiving training in group sessions were suspended pending receipt of individual training. Understanding of training iwas validated by post-test. rrhe Director of Pl, CNO, Director of UM, and/or ~he Director of Social Services are monitoring 100% of treatment plans through attendance and participation in all treatment planning meetings for a period of 90 days to confirm the plans are individualized and include all required elements. (Attachment F) Following this initial focused period of review, the CNO and Director of Social Services will randomly attend treatment team meetings to confirm the process and documentation are maintained per policy. Staff not in compliance will receive retraining and/or disciplinary action as appropriate. !Aggregated data will be reported monthly by the Director of Social Services to the Quality Committee and the Medical Executive WSXR11 Monitoring 4-30-14 and ongoing I II continuation sheel Page 13 ol 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, Clrt', STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG B 121 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 5. Patient 838 was admitted on 3/7/14. The MTP dated 317/14, for the problem "Depressed Mood with Suicidality" had the short -term goals "Patient will report any suicidal thoughts/impulses/urges to staff before acting on them," "Patient will report any 'command' hallucinations to staff before acting on them" and "Patient will rate their depression level at least (blank space} on a 1-10 scale for (blank space) consecutive days." 6. Patient C5 was admitted on 3/4/14. The MTP dated 3/4/14, for the problem "Psychotic Behaviors/Out of Contact with Reality" had the short-term goal "Patient will demonstrate decreased reaction to internal stimuli to 1 times (sic] per day." ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE B 121 Committee, and quarterly to the Governing Body. As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing that these purported documentatior issues hampered staff in providing the full rangE of appropriate treatment: Medical records document that nurses assessed patients each shift; clinical staff worked with patients on the unit and in activities and groups. Nurses administered medications ordered for patients and then assessed to confirm whether patients' condition improved. Nursing and clinical staff responded and provided treatment to each patient each day while determining the effectiveness of treatment and interventions and whether the patient was improving to be ready for discharge. Therefore, treatment was individualized and responded to the needs of each patient. 7. Patient CB was admitted on 3/10/14. The MTP dated 3/10/14, for the problem "Depressed Mood with Suicidallty" had the short-term goal "Patient will report any suicidal thoughts/impulses/urges to staff before acting on them." B. Patient C19 was admitted on 3/13/14. The MTP dated 3/13/14, for the problem "Depressed Mood without Suicidality had the short-term goal "Patient will have fewer than 1 episodes [sic] of tearfulness per day." 8. Interview During interview on 3/18/2014 at approximately 9:15 a.m., the Director of Behavioral Services, when shown short-term goals that were not measurable and required patients to monitor and report suicidal thoughts/impulses/urges, stated "Those are not very good goals." B 122 482.61(c)(1)(ili) TREATMENT PLAN FORM CMS-2567(02-99) Previous Versions Obsolete B 122 The Medical Director, Director of Pl, CNO, and j 04-18-2014 WSXR11 II conlinuallon •heel Page 14 of 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ kX1) PROVIOERISUPPLIERICLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 SlREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT Of DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 122 Continued From page 14 The written plan must include the specific treatment modalities utilized. This Standard is not met as evidenced by: Based on record review and interview, the facility failed to develop Master Treatment Plans for 8 of 8 active sample patients (A20, A24, 82, 928, 838, CS, CS, and C19) that included individualized treatment interventions with a specific purpose and focus. Many of the listed interventions were generic monitoring or routine clinical functions with identical wording for all patients with similar problems. Failure to clearly describe specific modalities on patients' MTPs can hamper staff's abilities to provide treatment based on Individual patient needs and may result in patients not receiving the full range of treatment needed. Findings include: A. Record Review 1. Patient A20's MTP dated 3/11/14 identified the problem, "Psychotic Behavior/Out of Contact with Reality." Interventions for this problem included (Social Work) "Psycho-educational groups related to coping skills." For the problem, "Depressed Mood with Suicldality," the interventions included (Nursing) "Special Precautions: Level of Observation Q (every) 15 min checks" and (Social Work) "Psycho-educational groups related to coping skills." 2. Patient A24's MTP dated 3/4/14 identified the problem, "Psychotic Behavior/Out of Contact with Reality." Interventions for this problem included, (Nursing) "Special Precautions: Level of FORM CMS-2587(02·99) Previous Versions Obsolete ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 122 the.Director of Social Services reviewed and revised the policy "Treatment Planning Process" lt:o clarify expectations in the following areas: All long term and short term goals must be stated in measurable, behavioral, observable lterms Individualized treatment interventions with la specific purpose and focus are to be clearly described so that treatment interventions are more than just generic monitoring or routine lclinical functions Identification of the specific individual(s) responsible for the intervention must include the name and credentials/ discipline. Staff need to identify alternative treatment interventions for patients unable or unwilling to attend regular programming. (Attachment E) The revised policy "Treatment Planning Process" was reviewed and approved by the Medical Executive Committee and the Governing Body. 04-18-2014 04-30-2014 The CNO and Director of Social Services provided training in group meetings to all RNs, Therapists/Social Workers, and Activities h"herapy staff on the revised "Treatment Planning Process" policy and expectations for adherence to development and documentation of individualized treatment plans for all patients which include the elements of: All long term and short term goals stated in measurable, behavioral, observable terms Individualized treatment interventions with a specific purpose and focus clearly described so that treatment interventions are more than ~ust generic monitoring or routine clinical functions Identification of the specific individual(s) responsible for the intervention including the name and credentials/ discipline. Identification of alternative treatment interventions for patients unable or unwilling to attend regular programming. Attendance at training was tracked by the HR Director, who used employee lists and sign in WSXR11 II conllnuallon sllee1 Page 15 cf 46 Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION nM9 NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CLIA IDENTIACATION NUMBER: c 03/19/2014 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 122 Continued From page 15 Observation 15 min checks," (Psychiatrist) "Order medication and titrate dosage as needed" and "Activity Therapy Group to (increase) coping skills." 3. Patient 82's MTP dated 3/12/14 identified the problem, "Substance Abuse/Dependence." Interventions for this problem included (Nursing) "Special Precautions: Level of Observation Q 15 min checks (to) ensure safety'' and (Social Work) "Process Group Therapy (to) learn effective communication." 4. Patient B28's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality." Interventions included (Nursing) "Administer routine medications at dosage and schedule ordered and prn (as needed) medication for depression" and (Psychiatrist) "Order medication and titrate dosage as needed." 5. Patient B38's MTP dated 317/14 identified the problem, "Depressed Mood with Suicidality." Interventions Included (Nursing) "Administer routine medications at dosage and schedule ordered and prn medication for depression" and (Nursing) "Special Precautions to ensure pt safety." 6. Patient C5's MTP dated 3/4/14 identified the problem, "Anxiety/Panic Attacks." Interventions included (Nursing) "Administer routine medication at dosage and schedule ordered and prn medications for anxiety" and (Social Work) "Psycho-educational groups related to sis (signs and symptoms) anxiety." 7. Patient C6's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality. •· Interventions Included (Nursing) "Special FORM CMS-2567(02-99) Previous Versions Obsolete COMPLETED STREET ADDRESS, CITY. STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG (X3) DATE SURVEY B.\MNG _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 04/04/2014 FORM APPROVED ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 122 sheets to validate attendance. Any staff members not receiving training in group sessions were suspended pending receipt of individual training. Understanding of training was validated by post-test. The Director of Pl, CNO, Director of UM, and/or the Director of Social Services are monitoring 100% of treatment plans through attendance and participation in all treatment planning meetings for a period of 90 days to confirm the plans are individualized and include all required elements. (Attachment F) Following this initial focused period of review, the CNO and Director of Social Services will randomly attend treatment team meetings to confirm the process and documentation are maintained per policy. Staff not in compliance will receive retraining and/or disciplinary action as appropriate. Aggregated data will be reported monthly by the Director of Social Services to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. Monitoring 4-30-14 and ongoing As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing that these purported documentation issues hampered staff in providing the full range of appropriate treatment: Medical records document that nurses assessed patients each shift; clinical staff worked with patients on the unit and in activities and groups. Nurses administered medications ordered for patients and then assessed to confirm whether patients' condition improved. Nursing and clinical staff responded and provided treatment to each patient each day while determining the effectiveness of treatment and interventions and whether the patient was improving to be ready for discharge. Therefore, treatment was individualized and responded to the needs of each patient. WSXR11 Ir canllnuallon sheet Page 16 ol 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (X1) PROVIDER/SUPPllER/CLIA IDENTIFICATION NUMBER: A. BUILDING _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 SlREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULl REGULATORY OR LSC IDENTIFYING INFORMATION) B 122 Continued From page 16 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) IX5) COMPLETION DATE 8122 Precautions: Level of Observation Q 15 min checks" and (Nursing) "Administer routine medication at dosage and schedule ordered and prn medication for depression." 8. Patient C19's MTP dated 3/13/14 identified the problem, "Aggressive/Assaultive Behavior." Interventions included (Psychiatrist) "Order medication and titrate dosage as needed" and "Activity Therapy Groups (to increase) coping skills." 8. Interview 1. In interview on 3118/14 at 2:30 p.m., the Director of Nursing acknowledged that the nursing interventions were generic, expected nursing duties and not individualized to the patient. 2. In Interview on 3/19 at 1:30-1 :45 p.m., the Director of Performance Improvement stated that the checklist format of the MTP encouraged staff to pick the same goals and interventions for patients with similar problems. B 123 482.61(c)(1)(iv) TREATMENT PLAN The written plan must include the responsibilities of each member of the treatment team. This Standard is not met as evidenced by: Based on record review and interview the facility failed to ensure that the discipline of all staff persons responsible for specific aspects of care were listed on the Master Treatment Plans for 8 of 8 active sample patients (A20, A24, 82, 828, 838, C5 , C6, and C19). This practice results in the inability to monitor discipline accountability for specific modalities. FORM CMS-2567(02·99) Previous Versions Obsolete B 123 The Medical Director, Director of Pl, CNO, and 04-18-2014 the Director of Social Services reviewed and revised the policy "Treatment Planning Process" to clarify expectations in the following areas: All long term and short term goals must be stated in measurable, behavioral, observable terms Individualized treatment interventions with a specific purpose and focus are to be clearly described so that treatment interventions are more than just generic monitoring or routine clinical functions Identification of the specific individual(s) responsible for the intervention must include the name and credentials/discioline. WSXR11 rr conllnueUon sl1ee1 Page 17 or 46 Printed; 04/04/2014 FORM APPROVED OMB NO. 0938-0~91 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: A.BUILDING _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19(2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 123 Continued From page 17 Findings Include: A. Record Review 1. Patients A20 (MTP 3/11 /14) had interventions with only the first names of staff members without identifying the discipline for the Psychiatrist, Nursing staff and Social Worker/Therapist. 2. Patient A24 (MTP 3/4/14) had interventions with only the first names of the assigned Social Worker/Therapist and Activity Therapist. 3. Patient 82 (MTP 3/12/14) had interventions with only the first names of staff members without identifying the discipline for the Psychiatrist, Nursing staff and Social Worker/Therapist. 4. Patient 828 (MTP 3/10/14) had interventions with only the first name of the assigned nursing staff. 5. Patient 838 (MTP 3ll/14) had interventions with only the first name of the assigned Social Worker/Therapist. 6. Patient C5 (MTP 3/4/14) had interventions with only the first name of the assigned Psychiatrist and Nurse. 7. Patient CB (MTP 3/10/14) had interventions with only the first name of the assigned nursing staff. 8. Patient C19 (MTP 3/13/14) had interventions with only the first name of the assigned Nurse. 8. Interviews FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG B 123 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CRDSS·REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Staff need to identify alternative treatment interventions for patients unable or unwilling to attend regular programming. (Attachment E) The revised policy "Treatment Planning Process" was reviewed and approved by the Medical Executive Committee and the Governing Body. 04-18-2014 The CNO and Director of Social Services 04-30-2014 provided training in group meetings to all RNs, Therapists/Social Workers, and Activities Therapy staff on the revised "Treatment Planning Process" policy and expectations for adherence to development and documentation of individualized treatment plans for all patients which include the elements of: All long term and short term goals stated in measurable, behavioral, observable terms Individualized treatment interventions with a specific purpose and focus clearly described so that treatment interventions are more than Uust generic monitoring or routine clinical functions Identification of the specific individual(s) responsible for the intervention including the name and credentials/discipline. Identification of alternative treatment interventions for patients unable or unwilling to attend regular programming. Attendance at training was tracked by the HR Director who used employee lists and sign in sheets to validate attendance. Any staff members not receiving training in group sessions were suspended pending receipt of individual training. Understanding of training was validated by post-test. The Director of Pl, CNO, Director of UM, and/or the Director of Social Services are monitoring 100% of treatment plans through attendance and participation in all treatment planning meetings for a period of 90 days to confirm the plans are individualized and include all required elements. (Attachment F) Following this initial focused period of review, the CNO and Director WSXR11 Monitoring 4-30-14 and ongoing fl conlinualian sheet Page 1B or 46 Printed: 04/04/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ (X1) PROVIOER/SUPPUER/CLIA IDENTIFICATION NUMBER: (XJ) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER RIVER POINT BEHAVIORAL HEALTH {X4)1D PREFIX TAG 0311912014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {X5\ COMPLETION Oo\TE B 123 of Social Services will randomly attend treatment team meetings to confirm the process and documentation are maintained per policy. Staff not in compliance will receive retraining and/or disciplinary action as appropriate. Aggregated data will be reported monthly by the Director of Social Services to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing that the purported failure to document the discipline of all staff members on the Master Treatment Plan violated this rule or hampered the facility's ability "to monitor discipline accountability for specific modalities": This rule requires the written plan to include the responsibilities of each member of the treatment team. The names of treatment team members appear in the sections of the MTP relevant to their various responsibilities, and first names were used in the portions of the MTP given to patients for safety reasons. Full names and disciplines of the staff members that develop the MTP are recorded on the first page of the MTP. Where just the first name of a staff member responsible for an intervention is listed, the treatment team and facility know the discipline of each staff member. The patients know which staff members are providing their treatment from their nametags. Therefore, the facility is able to monitor the treatment plan and know what staff members perform which interventions. FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 II continuation sheel Page 1BA or 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER: (XJ) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19(2014 STf!EET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH 6300 BEACH BLVD JACKSONVILLE, FL 32216 (X4)1P PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 123 Continued From page 18 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (K5l COMPLETION DATE B 123 1. In interview on 3/18/14 at 9:15 a.m., the Director of Behavioral Services agreed that the disciplines were not consistently entered on the MTPs. 2. In interview on 3/1 B/14 at 2:30 p.m., the Director of Nursing stated that the disciplines should have been identified on the MTPs. B 125 482.61 (c)(2) TREATMENT PLAN The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included. This Standard is not met as evidenced by: Based on observation, record review, and interview, the facility failed to: I. Ensure an adequate assessment of the readiness for discharge for 1 of 8 sample patients (C25). Being hospitalized beyond the time needed to reach optimal benefits results in lack of opportunity for patients' mental health and psychosocial improvement through transitional community services and community integration. II. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for 1 of 8 active patients (A24). This patient spent much of the time in bed or walking Idly in the hallway missing assigned programming. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge. Ill. Assess and treat the medical problems of 1 of B sample patients (C25), in order to identify FORM CMS-2567(02-99) Previous Versions Obsolete B 125 I. Adequate Assessment of the Readiness for Discharge The Medical Director, Director of Pl, and CNO 04-27-2014 provided education to the attending physicians, therapists/social workers, and RNs on the need to more thoroughly document the active treatment being provided and an updated patient status in progress notes to provide a better assessment of the patient's readiness for discharge or need for continued stay. The Utilization Management Director and her staff are monitoring all open medical records on the first weekday after admission and, at minimum, weekly thereafter for the presence of thorough documentation related to active treatment and updated patient psychiatric and medical status. (Attachment G) As needed, the UM staff may provide retraining to members of the treatment team on needed documentation. Monitoring begun 04-28-2014 & ongoing Aggregated results of the monitoring will be reported monthly by Director of Utilization Review to the Quality Committee and Medical Executive Committee and quarterly to the Governing Body. Monitoring begun 4-28-14 and ongoing As directed by CMS State Operations WSXR11 II conllnuatlan sheet Page 19 of 46 - - - - - - - - - ----- -----------------------------------------------------Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIOER/SUPPllERICLIA IDENTIFICATION NUMBER: 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 19 potentially treatable medical etiologies of mental status changes and identify potential concurrent medical illnesses. Failure to address medical issues and obtain a correct diagnosis and treatment results in a potential risk to patients ' lives/health and prevents patients from achieving an optimal level of functioning. Findings include: I. Failure to ensure adequate assessment of the readiness for discharge A. Patient Observations/Interviews During interviews with Patient C25 on 3/18/14 at 12:40 p.m. and on 3/19/14 at 11:00 a.m., Patient C25 reported the events leading to [her/his] involuntary admission to the facility and hospitalization was as follows: Patient C25 stated that four days prior to admission to the facility, [slhe] made a phone call with the assistance of a "friend" to the Veteran's Administration {VA) regarding Patient C25's disability determination for a back injury. Patient C25 stated that [s/he] had been in the process of being evaluated for the disabllfty for approximately eight years and had become distressed due to other recent financial losses. Patient C25 stated [slhe] had felt "up and down all day" and would sometimes "get down about being disabled." The friend advised Patient C25 that by telllng the VA that [slhe] was "going to harm myself," Patient C25 could" get the case moving along faster." Patient C25 stated that [s/he] made a call to the VA and reported to the VA representative that he was depressed and hopeless. Patient C25 reported that [s/he] received a call "from the VA" the following day FORM CMS-2587(02-99) Previous Versions Obsolete c 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP cooe RIVER POINT BEHAVIORAL HEALTH (X4)10 PREFIX TAG COMPLETED 8.WNG _ _ _ _ _ _ _~ - 104016 NAME OF PROVIDER OR SUPPLIER (X3) DATE SURVEY 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 125 Manual 30268, the hospital also provides the basis for disagreeing with the citation's implication that C25 was hospitalized longer than necessary and lost opportunity for improvement through "transitional community services and community integration": C25 was an involuntary admission pursuant to the Florida Baker Act because of statements he had made to the VA indicating suicidal ideation. Although C25 denied suicidal ideation at the hospital, staff needed to be sure he was safe and no longer met Baker Act criteria before discharging him. C25 refused to consent to the hospital's checking with either the VA or his family to corroborate his information. Therefore, he was held and evaluated until he appeared to be safe and could be discharged when he no longer met Baker Act criteria. 11. Treatment Based on Individual Patient Need 04-18-2014 The Medical Director, Director Pl, CNO, and Director of Social Services reviewed and revised the policy "Treatment Planning Process" to clarify expectations for development of individualized alternative therapy interventions within the treatment plan when a patient is unable/unwilling to attend programming. (Attachment E) The Director of Social Services developed a new policy "Alternative Therapy Interventions" to more clearly define when and how a patient should be provided alternative therapy if the patient is unwilling/unable to attend the programming on the unit. (Attachment I) 04-18-2014 The revised policy "Treatment Planning Process" and the new policy "Alternative Therapy Interventions" were reviewed and approved by the Medical Executive Committee and the Governing Body. 04-18-2014 The CNO and Director of Social Services 04-30-2014 provided training in group sessions to all RNs, TheraDists/Social Services and Active Theranv WSXR11 Jr conlinuatlon sheel Page 20 or 46 Printed: 04/04/2014 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN Of CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDERJSUPPLIERJCLtA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME Of PROVIDER OR SUPPLIER RIVER POINT BEHAVIORAL HEALTH 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP COOE 6300 BEACH BLVD JACKSONVILLE, FL 32216 (X4)1D PREFIX TAG 8125 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 20 and told the caller that [sAle] "was fine." Patient C25 reported that two days later, on the day of admission, [s/he] was in a dental chair having a dental procedure performed when [s/he] received another call "from the VA." (S/he] stated that [s/he] believed that the VA caller "hadn't followed protocol" during their previous conversations and Patient C25 felt "pressured" and "coerced" to respond that [s/he] was suicidal. Patient C25 staled that [sAle] belleved a law enforcement officer was listening in on the conversation. Patient C25 stated that a "swat team" entered the dental office and placed him custody. Patient C25 stated that [s/he] had not been depressed or suicidal during the week prior to admission. Patient C25 stated that [s/heJ had never been suicidal or hospitalized previously. Patient C25 reported being hopeful of the future as evidenced by plans to visit with his family in Atlanta on 3/15/14 and a planned neurosurgical procedure scheduled for 3/20/14 to address [her/his] back pain. During the interviews, Patient C25's affect was bright and [s/he] expressed humor multiple times. Patient C25 reported being angry about being held in the facility against [her/his] will and stated that [s/he] felt "like a commodity" in order for the facility to make money. Patient C25 stated that [s/he] had been prescribed bupropion for approximately eight years for "anxiety" but was started Cymbalta on 3/6114. Patient C25 slated that [s/he] did not feel depressed but felt "at their [the facility's] mercy'' and had to take the medication or [sAle] could not be discharged. Patient C25 reported being told by [her/his] attending psychiatrist on 3/17/14 that Patient C25 had "moderate depression" and on 3/18/14, that [s/he] had "depression and polysubstance abuse." FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 125 staff on the requirements in the policies "Treatment Planning Process" and "Alternative Therapy Interventions". Specific elements of policies addressed in training included: Patients are to be provided individual therapeutic intervention with therapist/nurse following non-attendance of assigned group intervention for first 24 hours of refusal or inability to attend groups. Development or revision of treatment plan is necessary after 24 hours of non-participation for any reason other than brief medical illness. Plan is to include new individual therapeutic interventions to address patient needs for all clinical disciplines. Documentation of individual interventions is necessary when patient refuses or is unable to participate in groups. Attendance at training was tracked by the HR Director who used employee lists and sign in sheets to validate attendance. Any staff members not receiving training in group sessions were suspended pending receipt of individual training. Understanding of training was validated by post-test. The Director of Social Services and Unit Program Directors are monitoring the documentation and treatment plans of any patients who are not attending unit programming to confirm that alternative therapeutic interventions are provided and documented when appropriate, and new or revised treatment plans are developed when a patient refuses or is unable to participate in group programming for more than 24 hours for any reason other than brief medical illness. (Attachment H) Staff not in compliance will receive retraining and/or disciplinary action as appropriate by the Department Director. Aggregated data will be reported monthly by Director of Social Services to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. WSXR11 Monitoring begun 4-30-14 & ongoing II contlnuallon sheet Page 21 of 46 Printed: 04/04/2014 FORM APPROVED nMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERV1r.i=5 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 21 8. Record Review 1. The "Report of Law Enforcement Officer Initiating Involuntary Examination" for Patient C25 dated 3/14/14 at 11:55 a.m. stated that Patient C25 "made a call to 'Disabled Veterans' stating [slhe] was very depressed and was thinking about 'ending it all'... [Patient C25] stated [slhe] was 'overwhelmed, depressed' and sometimes [s/he] felt 'life Is not worth living.'" 2. The "Integrated Assessment" dated 3/14/14 at 3:00 p.m., completed immediately prior to admission stated that Patient C25 "was BA [Baker Acted, i.e., involuntarily hospitalized] for Si's [suicidal ideations], however Pt [patient] denies. During assessment, pt agitated, cursing, stating 'I'll never ask the VA [Veterans Administration] for shoot.' ...minimizing suicidal statement & depression. Pt denies 5/H/l's [suicidal/homicidal ideations]. .. At end of assessment pt did admit to stating [s/he] would shoot self to VA." This assessment indicated that Patient C25 denied "self injurious behaviors and/or a recent suicide attempt," "history of suicidal/self-harm ideation/behaviors," "repetitive or persistent [suicidal ideation]," or "a specific plan." 3. The "Admit Orders" indicated Patient C25 was admitted 3/14/14 at 1 :30 p.m. 4. The "Psychiatric Evaluation" dated 3/15/14 at 5:03 p.m. stated that Patient C25 was a 49 year-old admitted 3/14/14 for "suicidal ldeations." The evaluation stated "Apparently, the patient called Disabled Veterans Affairs stating that [s/he] was depressed and was thinking about ending It all. The patient was on the phone for a long time with the hostage negotiator, which was one of the members of that team. The patient reported that FORM CMS-2.567(02-99) Pre11lou11 VersiOns Ob501ete ID PREAX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD SE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 125 As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing that A24's refusal to participate in groups violated any rule: The primary therapy for treating schizophrenia is medication and maintaining the patient in a safe environment while stabilizing the patient's condition with the proper level of medications. That therapy was provided. Additional treatment through group therapy was offered. Whether a voluntary or involuntary patient, A24 retained the constitutional right to refuse that additional treatment, and hospital staff appropriately documented each time the patient refused to participate in group therapy. Therefore, the fact that A24 refused to participate in group therapy does not support a finding of a violation of this rule. Ill. Medical Care The CNO has revised the policy "Laboratory 04-18-2014 Work" to clarify expectations for retrieval and review of laboratory results by the Charge RNs and physicians. Retrieval/review processes outlined in policy include: The Charge RN on each unit is responsible for retrieval of laboratory results from the computer connection with the contract laboratory at least once per shift. The Charge RN reviews results for any critical values or any other results that may require telephone notification of the physician, flags the reports for physician review/action, and places the reports in the patient medical record. With each retrieval of laboratory results, the Charge RN also prints off an aggregate report of abnormal laboratory results for the Internist tc trigger Internist review of abnormal results if requested by the attending physician. Attending physicians are responsible for reviewing lab results as indicated by date/time/signature, and noting abnormal results in progress notes. (Attachment J) WSXR11 II continuation sheet Page 22 ol 46 Printed: 04/04/2014 FORM APPROVED nMB Nn. n93s-o'.\01 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A.BUILDING _ _ _ _ _ __ ()(1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 22 [s/he] was overwhelmed. [S/he] felt like life was not worth llvlng. The patient was located and JSO [Jacksonville Sheriff Office] was sent to [his/her] place ... Today, the patient wants to deny all of this, stating those things happened way before [s/he] was called, that was a few days ago. [S/he] was feeling frustrated, since [sic] was not getting anywhere when [s/he] was trying to some help from the VA [Veterans Affairs], so [s/he] made those statements, but [s/he] did not really mean anything like that." The ''Past psychiatric history" stated "The patient denies any · treatment." The "Past medical history" stated "Chronic pain to [his/her] tower back, secondary to a fall..." The "Substance abuse history" stated ''The patient has a history of cocaine and alcohol abuse. [S/he] has been taking oxycodone and Oxycontin for a long time now." The section, "Mental Status Examination," identified the only findings as "looking mildly agitated. Mood is' depressed. Affect is non reactive (sic) .... Currently, [s/he] is not having any suicidal thoughts ... [S/he] has limited insight and judgment." Although there was no documentation in the "Psychiatric Evaluation" of previous major depressive episodes, the persistence of a depressive mood of at least two weeks, impairment of social or occupational functioning related to the depression, or the presence of (present most of the day nearly every day for a minimum of two consecutive weeks) other criteria for major depression (i.e., loss of interest or pleasure in most or all activities, insomnia or hypersomnia, change in appetite or weight, psychomotor retardation or agitation, low energy, poor concentration, thoughts of worthlessness or guilt, or recurrent thoughts about death or suicide), the psychiatric diagnosis was "Major depressive disorder; recurrent, severe, without psychotic features." FORM CMS.2567(02·99) Prellious Versions Obsolete ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 125 The policy "Laboratory Work" was reviewed and 04-18-2014 approved by the Medical Executive Committee and the Governing Body. The CNO provided training to all RNs, including 04-30-2014 House Supervisors in group settings on the process of retrieval, review, and flagging of laboratory reports per policy "Laboratory Work". All nurses were required to confirm understanding of the new policy with an attestation statement. Attendance at training was tracked by the HR Director who used employee lists and sign in sheets to validate attendance. Any staff members not receiving training in group sessions were suspended pending receipt of individual training. Understanding of training was validated by post-test. The Medical Director, Director of Pl, and CEO 04-18-2014 provided training to all attending psychiatrists and consulting internal medicine physicians in group settings on the revised policy and processes related to "Laboratory Work" and emphasized the importance of their reviewing laboratory results on patient charts during the next visit after ordering the lab tests. The Director of Pl maintained attendance records to ensure all physicians received training. Understanding has been validated via attestations statements. The 11-7 nursing staff are monitoring 100% of orders for laboratory work to confirm that reports are obtained from the laboratory in a timely fashion, flagged, and reviewed by the physician. (Attachment K) Aggregated data will be reported monthly by the CNO to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. Charge RNs that fail to retrieve and flag lab results during a shift are referred to the CNO for counseling and progressive discipline for repeat noncompliance. Physicians not in compliance with timely review of laboratory WSXR11 Monitoring 04-30-2014 and ongoing Ir conllnuatlon sheel Page 23 of 46 Printed: 04/04/2014 FORM APPROVED nus NO. rn:i3R.m\Q1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: A BUILDING _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 23 5. The "Psychosocial Assessment" for Patient C25 dated 3/16/14 at 11 :30 a.m. stated that the "Psychiatric/Substance History" "Treatment and Dates" was "None reported." "Affect" was indicated as "appropriate" and not "depressed." "Suicidal ideation" was ''denied." 6. The progress notes by the psychiatrist stated the following: a. The "Psychiatric/Medicine Progress Note" for Patient C25 by the attending psychiatrist on 3/16/14 at 10:40 a.m. indicated "Mood" was "apathic" but not "depressed." The "Updated Diagnosis and Problem List" was "unchanged." b. The "Psychiatric/Medicine Progress Note" for Patient C25 by the attending psychiatrist on 3/17/14 (no lime) indicated "Mood" was "euphoric" but not "depressed." The "Updated Diagnosis and Problem List" was illegible. c. The "Psychiatric/Medicine Progress Note" for Patient C25 by the attending psychiatrist on 3/18/14 (no time) indicated the "Updated Diagnosis and Problem List" was "296.34 & 300.00" [DSM IV codes for Major Depressive Disorder, Recurrent, with psychotic features and Anxiety Disorder, Not Otherwise Specified.] This progress note did not document criteria sufficient for recurrent major depression, psychosis, or anxiety disorder. ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 125 results will receive retraining and/or counseling by the Medical Director. Results for individual physicians are also maintained as part of their Ongoing Professional Practice Evaluation profile to be used for reappointment. As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing with the citation's implication that compliance with this rule required additional assessment and treatment of C25's medical problems: First, this rule requires the hospital to document all active therapeutic efforts, which the hospital did. The assessment of C25 included basic laboratory tests. The hospital had a system of putting test results on a clipboard for review by the internal medicine physician before being filed in each patient's medical record, and copies of C25's test results were on the clipboard for review at the time of the survey. Second, the hospital is a psychiatric hospital that has committed to treat psychiatric problems. The hospital responded appropriately to C25's lab results. None of the test results were critical values or indicated any acute medical problems requiring treatment (if within the hospital's capability) or transfer to an acute care facility. The positive opiate test result was consistent with the patient's eight-year history of chronic back pain and taking oxycodone and oxycontin. The hospital therefore placed the lab results for review and further direction (if any) by the internal medicine physician, after which they would have been filed in the medical record. This process did not violate this rule. 7. The progress notes by the nursing staff stated the following: a. The "24-hour RN Progress Note & Once a Day Suiclde Risk Assessment" dated 3/14/14 at 9:00 p.m. stated that Patient C25 was not "verbalizing FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 Ir continuation sheet Page 24 or 46 04/04/2014 Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMEIIIT OF DEFICIENCIES AND PLAN OF CORRECTION FORM APPROVED nMB NO 0938-0391 (X2) MULTIPLE CONS"ffiUCTION A.BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH 6300 BEACH BLVD JACKSONVILLE, FL 32216 (X4JID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 24 suicidal ideations or a desire to harm self," ''withdrawn, isolatlve, or guarded," "experiencing command hallucinations to harm self," or "verbalizing hopelessness, helplessness, anxiety, or depressed mood." Additionally, the note added that Patient C25 was "anxious & concerned about the events surrounding [her/his] Baker Act pnvoluntary hospitalization)." ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X51 COMPLETION DATE B 125 b. The "24-hour RN Progress Note & Once a Day Suicide Risk Assessment" dated 3/15/14 at 9:00 p.m. stated that Patient C25 was not "verbalizing suicidal ideations or a desire to harm self," "withdrawn, isolative, or guarded," "experiencing command hallucinations to harm self." or "verbalizing hopelessness, helplessness, anxiety, or depressed mood." Additionally, the note added that Patient C25 "denies SI/HI." c. The "24-hour RN Progress Note & Once a Day Suicide Risk Assessment" dated 3/16/14 at 11:24 a.m. stated that Patient C25 was not "verbalizing suicidal ideatlons or a desire to harm self," ''withdrawn, isolative, or guarded," "experiencing command hallucinations to harm self," or "verbalizing hopelessness, helplessness, anxiety, or depressed mood." Addltlonally, the note added that Patient C25 was "Compliant with care. Follows prompts and program schedule ... Patient is preoccupied with wanting to go home, but responds well to encouragement and support from staff. Denies current SI/HI [homicidal ideation], AN H [auditory/visual hallucinations). No signs of distress noted." d. The "24-hour RN Progress Note & Once a Day Suicide Risk Assessment" dated 3/17/14 at 1:15 p.m. stated that Patient C25 was ''withdrawn isolatlve, or guarded" but was not "verbalizing suicidal ideations or a desire to harm self," FORM CMS-2587(02-99) Previous Versions Obaolele WSXR11 II conllnuallon sheet Page 25 or 46 Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: COMPLETED c 03119/2014 STREET ADDRESS, Cm', STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG (X3) DATE SURVEY B. 'MNG _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 04/04/2014 FORM APPROVED 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FUU. REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 25 "experiencing command hallucinations to harm self," or ''verbalizing hopelessness, helplessness, anxiety, or depressed mood." Additionally, the note added that Patient C25 was "observed ... particlpating in treatment. Pt is very irritated [with] being admitted here." ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COJIIPLETION DATE B 125 e. The "24-hour RN Progress Note & Once a Day Suicide Risk Assessment" dated 3/18/14 at 9:00 p.m. stated that Patient C25 was not "verbalizing suicidal ideations or a desire to harm self," "withdrawn, isolative, or guarded," "experiencing command hallucinations to harm self," or "verbalizing hopelessness, helplessness, anxiety, or depressed mood." Additionally, the note added that Patient C25 was "cooperative [with] staff" and "denies SI." 8. The progress note by MSW 1 dated 3/17/14 at 10:45 a.m., titled "Tx [treatment] plan response," stated "Pt. [patient] met w/ [with] tx team to discuss plan of care & development. .. [S/he] reports a couple of conversations w/ a VA representative over the course of last week stating [s/he] felt coersed (sic) into stating [slhe] was feeling suicldal...[S/he) denies SI [suicidal ideation]. .. " C. Staff Interviews 1. During an interview with MD 3, the attending psychiatrist for Patient C25, on 3/19/14 at 11:25 a.m., he described Patient C25 as "Irritable, angry, and easily upset." He stated that Patient C25 was "an extremely angry [wo/man] ... [s/he] threatened me with a [law) suit." When asked what Patient C25's current diagnoses were, MD 3 stated "probably a mood disorder. I've only known [her/him] a short time ... maybe bipolar affective disorder, mixed or depression NOS [not FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 II continuation sheet Page 26 of 46 Printed: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 04/04/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X 1) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER: (XJ) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 03/19/2014 STREET ADDRESS, CITY, STATE. ZIP CODE 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 26 otherwise specified]." When asked what symptoms and history were available to justify these diagnoses, MD 3 stated the only symptoms were "angry, irritable" and "mildly hostile." MD 3 stated "I don't have information to make a diagnosis... ! still don't have an established diagnosis." MD 3 stated he did not know the circumstances leading to the admission of Patient C25 other than suicidal threats made to the VA. MD 3 stated that he was not aware whether any collateral information had been obtained from the VA. He stated "we could have gotten information from the VA." MD 3 acknowledged that he was unable to locate any documentation in the medical record by nursing, social work, or other staff that Patient C25 evidenced irritabir.ty or anger in setting other than with MD 3. MD 3 agreed that Patient C25 may have felt anger and irritability based on [his/her] experiences leading to hospitalization. MD 3 acknowledged that he was not aware of any expressed suicidal ideation or self-harm by Patient C25 during hospitalization and that Patient C25 repeatedly stated that [slhe] was not going to harm [her/himsel~. MD 3 staled that Patient C25 was to be discharged on 3/19/14 but acknowledged that there had been no change in Patient C25's mental status or additional information obtained since the time of admission. ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 8125 2. During an inte,view and review of Patient C25's medical record with the Medical Director on 3/18/14 at 1:30 p.m., he stated that Patient C25 was hospitalized "to get a suicide risk assessment." He stated that the VA and friends had not been contacted and the "assessment was not complete." During an interview with the Medical Director on 3/19/14 at 12:35 p.m., he stated that he had "clinical concerns" about Patient C25 and had asked MD3 to review his care of Patient C25 on 3/18/14. FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 II contlnuellon sheel Paga 27 or 46 Printed: 04/04/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, Ct1Y, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 125 Continued From page 27 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 8125 II. Treatment based on individual patient need Patient A24 was a 31 year-old admitted 314/14 with a diagnosis of "Schizophrenia, paranoid, chronic with acute exacerbation." A. Observations 1. Observations on 3117/14 at 3:15 p.m. revealed Patient A24 lying in bed in his/her room during the assigned treatment program. 2. Observations on 3/18/14 at 10:10 a.m. revealed Patient A24 lying in bed In his/her room during the assigned treatment program. B. Record review 1. According to the Psychiatric Evaluation dated 3/5/14, PatientA24 was admitted because of psychosis and threatening [his/her] mother. 2. Review of Patient A24's group notes for 316/14-3/17/14 (only sheets provided for staff as proof of treatment since admission on 3/4/14) revealed that s/he has refused to attend 25 of 25 • groups/activities offered. These notes indicated that the group leader 4 met with Patient A2 individually only seven times during this period when the group was not attended. 3. Review of the master treatment plan (3/4/14) revealed a list of general modalities for the treatment of Patient A24. These were stated as "Psycho-educational groups related to psychosis," "Process group therapy," and "Activity Therapy groups." Even though this patient was admitted with psychosis and refused much of his/her assigned treatment activities, FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 Ir conlinuaUon sheel Page 28 of 46 Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 04/04/2014 FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: {X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)10 PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 28 there were no specific interventions for this patient's specialized needs documented in the treatment plan. ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 125 B. Staff Interviews 1. During an interview with MD 4 on 3/19/14 at 9:30 a.m., he acknowledged that Patient A24 had not attended group therapies during this hospitalization. He acknowledged that the only documented treatments were medications. 2. During an interview with the Medical Director and Director of Behavioral Services on 3/19/14 at 12:35 p.m., they acknowledged that PatientA24 had not been attending group therapies and no alternative treatments were documented other than medications and a few individual contacts by group leaders. The Director of Behavioral Services acknowledged that the treatment plan had not b~en revised to provide alternative treatments. Ill. Medical Care A. Record Review 1. Patient C25 was admitted 3/14/14 at 1:30 p.m. 2. The Psychiatric Evaluation dated 3/15/14 at 5:03 p.m. stated that Patient C25 was a 49 year-old admitted 3/14/14 for "suicidal ideations." The "Past medical history" stated "Chronic pain to [his/her] lower back, secondary to a fall, history of high blood pressure, seasonal allergies." The diagnoses were "Axis I: 1. Major depressive disorder; recurrent, severe, without psychotic features" and "R/0 opioid dependence," "Axis Ill: 1. Hypertension" and "2. Chronic pain syndrome." FORM CMS-2567(02-99) Previous Versions Obaalele WSXR11 If conllnuallon sheet Page 29 of 46 Printed: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 04/04/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 03/19/2014 STREET ADDRESS, Cf'TV, STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD JACKSONVILLE, FL 32216 RIVER POINT BEHAVIORAL HEALTH (X4)10 PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 29 ID PREFIX TAG PROV1DER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 8125 3. The "Consultation" [medical history and physical examination] dated 3/15/14 at 6:34 p.m. stated the "Past Medical History" and "Assessment" was "1. Chronic back pain, allegedly scheduled for surgery this week," "2. Chronic neck pain," "3. Hypertension," and "4. Neuropathy." 4. The "Admit Orders" dated 3/14/14 at 1:30 p.m. indicated the following laboratory studies were ordered: "CBC (complete blood count] with Diff [differential]," "Comprehensive Metabolic Profile," "Urine Drug Screen," "TSH [thyroid stimulating hormone," and "urinalysis." 5. A review of the "Lab Report" from an outside laboratory indicated the laboratory samples were collected on 3/14/14 at 2:41 p.m. and final reports were generated on 3/15/14 between 1:55 p.m. and 3:20 p.m. However, a review of the medical record on 3/19/14 at 11:45 a.m. indicated that copies of these reports were not in the medical record and there was no indication that these reports had been reviewed by a physician. 6. A review of the laboratory report for the CBC collected from Patient C25 on 3/14/14 at 2:41 p.m. indicated low values for the following studies: RBC [red blood count] 4.09 M/ul [thousands per cubic millimeter] [reference range 4.70-5.30 M/ul), HGB [hemoglobin]:: 12.9 g/dl [grams per deciliter] [reference range 14.Q...18.0], HCT [hematocrit) = 41.1 % [reference range 42.0-52.0%]. A review of the laboratory report for the TSH level collected from Patient C25 on 3/14/14 at 2:41 p.m. indicated a low value of 0.218 ulU/mL [micro international units per milliliter] [reference range 0.510-6.270 ulU/mij. A review of the urine "Drug Panel" indicated a = FORM CMS-2567(02-99) Previous Veralons Obsolete WSXR11 If conlinuallon shaet Page 30 of 46 Prinled: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIOERISUPPLIER/CUA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CllY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 30 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY! {XS) COMPLETION DATE B 125 negative result for all substances measured except a positive result for opiate. 7. A review of the medical record on 3/19/14 at 12:00 p.m. indicated that Patient C25 remained hospitalized for five days without documented assessment or interventions for abnonnal laboratory values indicating possible anemia, hyperthyroidism, or the presence or absence of recent substance abuse. B. Staff Interview During an interview with MD 3, the attending psychiatrist for Patient C25, on 3/19/14 at 11:25 a.m., Indicated that he was not aware of the results of laboratory studies ordered at the time of admission for Patient C25. B 133 482.61(e) DISCHARGE PLANNING The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient's hospitalization. This Standard is not met as evidenced by: Based on interview and record review, the facility failed to provide a discharge summary for each patient who has been discharged that Included a recapitulation of the patient's hospitalization including the circumstances of admission, assessments, and treatments provided for 1 out of 5 discharged patients (02}. This deficiency results in a fallure to communicate in a timely manner psychiatric assessments and discharge plan with providers providing follow-up care. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete B 133 The Medical Director reviewed and reaffirmed 04-04-2014 that the Medical Staff Rules and Regulations require a Discharge Summary to be completed within 30 days of discharge. (Attachment L) The Medical Director provided retraining to the 04-04-2014 attending physicians in group settings on the requirement to have Discharge Summaries completed within 30 days of discharge. The Director of Pl maintained attendance records to ensure all physicians received training. The Director of Pl provided training to physician 04-11-2014 extenders who assist some physicians in dictation of discharge summaries of the expectation to have Discharge Summaries dictated within 15 days of discharge to allow adequate time for physicians to review and authenticate the reports within 30 days of discharge. Training was provided in group training sessions. The Director of Pl maintained attendance records to ensure all physicians received training. WSXR11 II conllnuallon sheet Page 31 or 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A.BUILDING _ _ _ _ _ __ (X1) PROVIOER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)10 PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 133 Continued From page 31 A. Record review Patient D2 (date of discharge, 1/2/14): No discharge summary was completed. B. Interview During an interview with the Medical Director on 3/19/14 at 12:35 p.m., he acknowledged that the medical record for Patient 02 did not contain a discharge summary. B 135 482.61(e) DISCHARGE PLANNING The record of each patient who has been discharged must have a brief summary of the patient's condition on discharge. This Standard is not met as evidenced by: Based on interview and record review, the facility failed to provide a discharge summary that summarized all treatment received in the hospital and the extent to which goals established in the patient's treatment plan had been met for 2 out of 4 discharged patients (D3 and 05). This deficiency results in a failure to communicate in a timely manner the course of treatment and patient ' s response with providers providing follow-up care. Findings include: A. Record Review Patient D3 (date of discharge, 1/1/14) and Patient 05 (date of discharge, 1/2/14) 1. The sections entitled "Hospital Course and Prognosis" were generic and almost Identical for both Patient 03 and 05 even though Patient 03 FOAM CMS-2567(02-99) Previous Versions Obsolete 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE B 133 The Director of HIM is reviewing 100% of Monitoring Discharge Summaries for timeliness and begun content. (Attachment M) Weekly notification of 04-21-2014 pending/late discharge summaries is provided /& ongoing to each physician every Friday, with a summary list provided to the CEO and Medical Director so that they may address any deficiency with individual physicians immediately. Aggregated data will be reported monthly by Director of Pl to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. Results for individual physicians are also maintained as part of their Ongoing Professional Practice B 135 Evaluation profile to be used for reappointment. B 135: The Medical Director and Director of Pl 04-04-2014 reviewed and revised the Medical Staff Rules and Regulations to provide clearer direction for the required elements of the Discharge Summary to include a summary of all treatment received in the hospital and the extent to which goals established in the treatment plan have been met at the time of discharge. (Attachment L) The revised Medical Staff Rules and Regulations were reviewed and approved by the Medical Executive Committee and the Governing Body. b4-04-2014 The Medical Director provided training in group 04-04-2014 settings to all attending psychiatrists on the requirement to include a summary of all treatment received in the hospital and the extentto which goals established in the treatment plan have been met at the time of discharge in the Discharge Summary. The Director of Pl maintained attendance records to ensure all physicians received training. The Director of Pl provided training to all 04-11-2014 physician extenders who assist some physicians in dictation of discharge summaries of the expectation to include a summary of all treatment received in the hospital and the WSXR11 II conllnualion sheet Page 32 or 46 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, Cl1Y, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X-1)10 PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 135 Continued From page 32 was hospitalized for only 5 days while Patient 05 was hospitalized for 26 days. Patient D3's diagnosis was "Bipolar disorder, type I" while Patient D5's diagnosis was "Major depressive disorder." 2. For Patient 03, the "Hospital Course and Prognosis" section was as follows: ''The patient was admitted to the inpatient unit. IM"lile receiving treatment, [snie] was closely monitored by myself (sic), as well as the treatment team. The patient was continued on q. [every] 15-minute observation for safety. The patient was medically stable. The patient participated In individual and group sessions pertinent to [herniis] diagnosis, including substance abuse groups. Please see treatment planning and the therapist's notes regarding the patient's participation and progress during sessions. The patient tolerated medication changes well with Improvement in [his/her] mood and behavior noted. There was a decrease in the patient's symptoms of depression noted. The patient's overall response to treatment was good and there was an overall decrease i~ [his/her] symptoms. [S/he] was discharged with no acute safety issues noted." ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TD THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE B 135 extent to which goals established in the treatment plan have been met at the time of discharge. Training was done in group settings. The Director of Pl maintained attendance records to ensure all physicians received training. The Director of HIM is reviewing 100% of Discharge Summaries for timeliness and content. (Attachment M) Aggregated data will be reported monthly by the Director of HIM to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. Deficient discharge summaries are referred back to the attending physicians for addendum to be completed to ensure thorough discharge summaries are done. Results for individual physicians are also maintained as part of their Ongoing Professional Practice Evaluation profile to be used for reappointment. Monitoring begun 4-21-14 & ongoing As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing that the evidence cited by this citation violates this rule: The rule requires only that there be a "brief summary of the patient's condition on discharge." The quoted portions o1 the discharge summaries for 03 and 05 met that requirement. 3. For Patient 05, the "Hospital Course and Prognosis" section was as follows: ''The patient was admitted to the Inpatient unit. While receiving treatment, [snie] was closely monitored by myself (sic}, as well as the treatment team. The patient was continued on q. [every] 15-minute observation for safety. The patient was given a physical examination on the unit completed by [medical provider]. During the hospital stay, the patient participated in individual and group sessions pertinent to [her/his] diagnosis. Please see treatment planning and FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 If continuation sheet Page 33 of '16 Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: 04/04/2014 FORM APPROVED OMB NO. 09 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED c 104016 03/19/2014 -0391 Printed: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 04/04/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & ~ 1EDICAID SERVICES OMB NO. 0938-0391 (X21 MULTIPLE CONSTRUCTION A.BUILDING _ _ _ _ _ __ (Xt) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CllY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 135 Continued From page 33 the therapist's notes regarding the patient's participation and progress during sessions. The patient tolerated medication changes well with Improvement ln [his/her] mood and behavior noted. There was a deaease in the patient's symptoms of depression noted. The patient was noticed to have improvements with a brighter affect and improvements with sleep and appetite. The patient's overall response to treatment was good. [S/he] was discharged with no acute safety issues noted." ID PREFIX TAG PROVIDER'S PL.AN OF CORRECTION (EACH CO~RECTIVEACTION SHOULD BE CROSS·REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE B 135 B. Interview During an interview with the Medical Director on 3/19/14 at 12:35 p.m., he acknowledged that the "Hospital Course and Prognosis" sections of the discharge summaries for Patients 03 and 05 were generic and did not contain sufficient information to summarize the treatment and each patient's response. B 144 482.62(b)(2) MEDICAL STAFF B 144 The director must monitor and evaluate the quality and appropriateness of services and treatment provided by the medical staff. This Standard is not met as evidenced by: Based on interview and document review, the Medical Director failed to provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to: I. Ensure that 2 of B active sample patients (C6 and C19) received a psychiatric evaluation containing sufficient information to justify diagnoses and treatment. For Patient C6, the psychiatric evaluation failed to document a FORM CMS-2587(02-99) Previous Versions Obsolete I. The hospital provided training to physicians 04-22-2014 and implemented monitoring to confirm that medical record documentation is completed in accordance with policy and the rules. Please see detailed response to B 110. WSXR11 II canllnuetlon sheet Pane 34 of 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CON~TRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG c B.WING _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER (X3) DATE SURVEY COMPLETED 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 144 Continued From page 34 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS} COMPLETIOtl DATE B 144 developmental disability noted by staff during hospitalization and from history. In addition, a diagnosis and treatment for alcohol abuse were continued despite evidence from the community that the patient did not consume alcohol. For Patient C19, the psychiatric evaluation failed to reflect the cognitive problems noted by staff during hospitalization and from history. This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate master treatment plan. (Refer to 8110) II. Ensure that physicians participated in the collaborative development of the treatment plans for 4 active patients who were added to the sample in order to evaluate the treatment planning process. In addition, 6 of 8 sample patients (A20, A24, 82, 828, CB, and C19) had initial MTPs that did not have a physician signature. The space on the MTP form where the physician was to sign contained the statement, "Physician Approval of Treatment Plan." Failure of the physician to direct the treatment team in the development of individualized patient goals and needed therapeutic interventions places the responsibility for patient treatment on the other team members potentially depriving the patient of needed treatment and possibly increasing the length of stay. (Refer to B 118) II. The hospital reviewed and revised pertinent 04-30-2014 policies and processes, provided training to hospital staff and physicians, and implemented monitoring to confirm that medical record documentation reflects the physicians' involvement in developing and approving treatment plans. The hospital also disagrees with some of the statements in this portion of the citation. 111. Provide Master Treatment Plans that included short-term goals stated in measureable, patient focused terms for 8 of 8 active sample patients (A20, A24, 82, 828, 838, C5, CB, and C19). In addition, 5 of 8 active sample patients (A20, 82, 828, 838, and CB) had unmeasurable goals that required patients to report to staff thoughts of harm to self or others, placing the responsibility of treatment on the patient. These deficient 111. The hospital reviewed and revised pertinent 04-30-2014 policies and processes, provided training to hospital staff, and implemented monitoring to confirm that medical record documentation in treatment plans reflects short-term goals stated in measurable, patient focused terms. The hospital also disagrees with some of the statements in this portion of the citation. FORM CMS-25B7(D2-9S) Previous Versions Obsolete Please see detailed response to B 118. Please see detailed response to B 121. WSXR11 II continuation sheet Page 35 or 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID ~;:;::·,.::;:;::5 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ {)ct) PROVIDeR/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 0311912014 STREET ADDRESS, CITY, STATE. zip CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PRE RX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED ev FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 144 Continued From page 35 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (KS) COMPLETION DATE B 144 practices hamper the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of staff interventions based on changes in patient behaviors. (Refer to 8121) IV. Develop and document comprehensive treatment plans to include physician interventions based on the Individual needs of 8 of 8 sample patients (A20, A24, 82, 828, 838, C5, C6, and C19). This failure resulted in absence of specific plans to direct staff In the implementation, evaluation, and revision of care based on individual patient findings. Findings include: A. Record Review 1. PatientA20's MTP dated 3/11/14 identified the problem, "Psychotic Behavior/Out of Contact with Reality." No interventions were identified to be provided by the psychiatrist. 2. Patient A24's MTP dated 3/4/14 Identified the problem, "Psychotic Behavior/Out of Contact with Reality." The only intervention to be provided by the psychiatrist was "Order medication and tHrate dosage as needed." 3. Patient 82's MTP dated 3/12/14 identified the problem, "Substance Abuse/Dependence." No Interventions were Identified to be provided by the psychiatrist. 4. Patient B2B's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicldality." The only intervention to be provided by the psychiatrist was "Order medication and titrate dosage as needed." FORM CMS-2567(02-99) Previous Versions Obsolete IV. The Medical Director, Director of Pl, CNO, 04-18-2014 and the Director of Social Services reviewed and revised the policy "Treatment Planning Process" to clarify expectations in the development of individualized treatment inventions with a specific purpose and focus are to be clearly described so that treatment interventions are more than just generic monitoring or routine clinical functions, includin~ physician interventions. (Attachment E) The revised policy "Treatment Planning Process" was reviewed and approved by the Medical Executive Committee and the Governing Body. 04-18-2014 The Medical Director and Director of Pl 04-22-2014 provided training to all attending psychiatrists in group settings on the revised "Treatment Planning Process" policy and expectations for adherence to development and documentation of individualized treatment plans for all patients, including the elements of individualized physician interventions with a specific purpose and focus clearly described so that treatment interventions are more than just generic monitoring or routine clinical functions. The Director of Pl maintained records of attendance to ensure training was receive by all attending psychiatrists. Validation of understanding of training was accomplished via attestation statements. The Director of Pl, CNO, Director of UM, and/or the Director of Social Services are monitoring 100% of treatment plans through attendance and participation in all treatment planning WSXR11 Monitoring begun 4-30-14 & ongoing II continuallon sheet Page 36 or 46 Printed: 04/04/2014 FORM APPROVED OM8 NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSmUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 smEET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 144 Continued From page 36 5. Patient B38's MTP dated 3/7/14 identified the problem, "Depressed Mood with Suicidality." No interventions were identified to be provided by the psychiatrist. 6. Patient C5's MTP dated 3/4/14 identified the problem, "Anxiety/PanlcAttacks." No interventions were identified to be provided by the psychiatrist. 7. Patient CS's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality." No interventions were identified to be provided by the psychiatrist. 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 144 meetings for a period of 90 days to confirm the plans are individualized and include all required elements. (Attachment F) Following this initial focused period of review, the CNO and Director of Social Services will randomly attend treatment team meetings to confirm the process and documentation are maintained per policy. Aggregated data will be reported monthly by the Director of Social Services to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. Results for individual physicians are also maintained as part of their Ongoing Professional Practice Evaluation profile to be used for reappointment. 8. Patient C19's MTP dated 3/13/14 identified the problem, "Aggressive/Assaultive Behavior." The only intervention to be provided by the psychiatrist was "Order medication and titrate dosage as needed." B. Interview During an interview with the Medical Director on 3/19114 at 12:30 p.m., he acknowledged that the treatment plans did not list individuallzed treatment interventions, including treatment focus, based on the patients' needs. He acknowledged that there were no physician Interventions present on the treatment plans. V. Ensure that the discipline of all staff persons responsible for specific aspects of care were listed on the Master Treatment Plans for 8 of 8 active sample patients (A20, A24, 82, 828, 838, C5, CS, and C19). This practice results in the inability to monitor discipline accountability for specific modalities. (Refer to 8123) V. The hospital reviewed and revised pertinent 04-30-2014 policies and processes, provided training to hospital staff, and implemented monitoring to confirm that medical record documentation in treatment plans reflects staff credentials. The hospital also disagrees with some of the statements in this portion of the citation. Please see detailed response to B 123. FORM CMS-2567(02-99) Previous Ven;lons Obsolete WSXR11 If conrlnu•Uan slreel Page 37 of 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CllY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)10 PRERX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 144 Continued From page 37 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE B 144 VI. Ensure an adequate assessment of the readiness for discharge for 1 of 8 sample patients (C25). Being hospitalized beyond the time needed to reach optimal benefits results in lack of opportunity for patients' mental health and psychosocial improvement through transltional community services and community integration. (Refer to 8125 I) 04-30-2014 VI. The hospital provided training to hospital staff physicians and implemented monitoring to confirm that medical record documentation reflects thorough assessments of patients' condition and their readiness for discharge. The hospital also disagrees with some of the statements in this portion of the citation. VII. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for 1 of 8 adive patients (A24). This patient spent much of the time in bed or walking idly in the hallway missing assigned programming. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge. (Refer to 8125 II) VII. The hospital reviewed and revised 04-30-2014 pertinent policies and processes, developed a new policy, provided training to hospital staff, and implemented monitoring to confirm that patients are provided with alternative treatment based on individualized treatment needs when they refuse to attend programming. The hospital also disagrees with some of the statements in this portion of the citation. VIII. Assess and treat the medical problems of 1 of 8 sample patients (C25), In order to identify potentially treatable medical etiologies of mental status changes, and identify potential concurrent medical illnesses. Failure to address medical Issues and obtain a correct diagnosis and treatment results in a potential risk to patients' lives/health and prevents patients from achieving an optimal level of functioning. (Referto 8125111). VIII. The hospital reviewed and revised 04-30-2014 pertinent policies and processes, provided training to hospital staff and physicians, and implemented monitoring to confirm that medical record documentation includes all active treatment provided, including medical treatmen within the hospital's capability. The hospital also disagrees with some of the statements in this portion of the citation. IX. Provide a discharge summary for each patient who has been discharged that included a recapitulation of the patient's hospitalization including the circumstances of admission, assessments, and treatments provided for 1 out of 5 discharged patients (D2). This deficiency results In a failure to communicate in a timely manner psychiatric assessments and discharge plan with providers providing follow-up care. FORM CMS-2567(02-99) Previous Versions Obsolete Please see detailed response to B 125 I. Please see detailed response to B 125 II. Please see detailed response to B 125 111. IX. The hospital reviewed and reaffirmed pertinent provisions in the Medical Staff Rules and Regulations, provided training to physicians and physician extenders, and implemented monitoring to confirm that discharge summaries met requirements. 04-30-2014 Please see detailed response to B 133. WSXR11 II conllnual!on sheet Page 38 of 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2} MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIOER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDl:R OR SUPPLIER 03/19/2014 STREET ADDRESS, CllY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)10 PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 144 Continued From page 38 (Refer to 8133) ID PREFIX TAG The director must demonstrate competence to participate in interdisciplinary fonnulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished. This Standard is not met as evidenced by: Based on record review and interview, the Director of Nursing failed to: I. Ensure that the Master Treatment Plans included individualized nursing interventions with a specific purpose and focus for 7 of 8 sample patients. (A20, A24, 82, 828, 838, CS, and CS) Many of the listed interventions were generic monitoring or routine nursing functions with identical wording for all patients with similar problems. Failure to clearly describe specific nursing modalities on patients' MTPs can hamper staff's abilities to provide Individualized nursing care to address patient needs and may result in patients not receiving the full range of treatment needed. 11. Ensure that the nursing staff was identified by discipline for 6 of 8 sample patients. (A20, 82, FORM CMS-2567(02·99) Previous Versions Obsolete (XS) COMPLETION DATE B 144 X. The hospital reviewed and revised pertinent 04-30-2014 provisions in the Medical Staff Rules and Regulations, provided training to physicians anc physician extenders, and implemented monitoring to confirm that discharge s.ummaries met requirements. The hospital also disagrees with this section of the citation. X. Provide a discharge summary that summarized all treatment received in the hospital and the extent to which goals established in the patient's treatment plan had been met for 2 out of 4 discharged patients (03 and 05). This deficiency results in a failure to communicate in a timely manner the course of treatment and patient's response with providers providing follow-up care. (Refer to 8135) B 148 482.62(d)(1) NURSING SERVICES PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Please see detailed response to B 135. B 148 I. Nursing Interventions The Medical Director, Director of Pl, CNO, and 04-18-2014 the Director of Social Services reviewed and revised the policy ''Treatment Planning Process' to clarify expectations in the following areas: Individualized treatment inventions with a specific purpose and focus are to be clearly described so that treatment interventions are more than monitoring or routine clinical functions, including nursing interventions Identification of the specific individual(s) responsible for an intervention must include name and credentials/discipline. (Attachment E The revised policy "Treatment Planning Process" was reviewed and approved by the Medical Executive Committee and the Governing Body. 04-18-2014 The CNO and Director of Social Services 04-30-2014 provided training in group settings to all RNs, Therapists/Social Workers, and Activities Therapy staff on the revised "Treatment Planning Process" policy and expectations for adherence to development and documentation of individualized treatment plans for all patients which include the elements of: Individualized treatment inventions for nursing with a specific purpose and focus WSXR11 II conllnuatlon sheet Page 39 of 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & I EDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (X1) PROVIDER/5UPPLIER/CLIA IDENTIFICATION NUMBER: A. BUILDING _ _ _ _ _ __ B. IMNG _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER (X4)1D 8148 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 39 828, CS, CS, and C19). This practice results in the inability to monitor disclplfne accountability for specific modalities. Findings include: I. Nursing Interventions A. Record Review 1. Patient A20's MTP dated 3/11/14 for the identified problem, ''Depressed Mood with Suicidality." The only nursing intervention for this problem was ''Special Precautions: Level of Observation Q (every) 15 min checks." 2. Patient A24's MTP dated 3/4/14 identified the problem, "Psychotic Behavior/Out of Contact with Reality." The nursing Intervention for this problem was "Special Precautions: Level of Observation 15 min checks." 3. Patient 82's MTP dated 3/12/14 Identified the problem, "Substance Abuse/Dependence." The only nursing Intervention for this problem was "Special Precautions: Level of Observation Q 15 min checks (to) ensure safety." 4. Patient B28's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidalily." The nursing interventions included •Administer routine medications at dosage and schedule ordered and prn (as needed) medication for depression." 5. Patient 838's MTP dated 3f7/14 identified the problem, "Depressed Mood with Suicldality." The nursing interventions were "Administer routine medications at dosage and schedule ordered and prn medication for depression" and "Special Precautions to ensure pt safety." FORM CMS-2567(02-99) Previous Versions Obsolete c 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH PREFIX TAG (XJ) DATE SURVEY COMPLETED ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 148 clearly described so that treatment interventions are more than just generic monitoring or routine clinical functions Identification of the specific individual(s) responsible for the intervention including the name and credentials/discipline. Attendance at training was tracked by the HR Director who used employee lists and sign in sheets to validate attendance. Any staff members not receiving training in group sessions were suspended pending receipt of individual training. Understanding of training was validated by post-test. The Director of Pl, CNO, Director of UM, and/or the Director of Social Services are monitoring 100% of treatment plans through attendance and participation in all treatment planning meetings for a period of 90 days to confirm the plans are individualized and include all required elements. (Attachment F) Following this initial focused period of review, the CNO and Director of Behavioral/Social Services will randomly attend treatment team meetings to confirm the process and documentation is maintained per policy. Staff not in compliance will receive retraining by the CNO and/or disciplinary action as appropriate. Aggregated data will be reportec monthly by the CNO to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. Monitoring begun 04-30-2014 & ongoing As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing that patients did not receive individualized and appropriate treatment: Medical records document that patients received individualized and appropriate treatment. For example, while the MTP may have described g'enerally that the plan was to "administer routine medications at dosage," each patient's attending physician ordered specific medications based on evaluation of the patient and the patient's condition, and nurses administered the medication in accordance with orders. Anv special precautions ordered were tr cantinuallon sheet Page 40 al 46 WSXR11 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & I EDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH 6300 BEACH BLVD JACKSONVILLE, FL 32216 (X4) IO PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FUU. REGULATORY OR LSC IDENTIFYING INFORMATION) B 148 Continued From page 40 6. Patient C5's MTP dated 3/4/14 identified the problem, "Anxiety/Panic Attacks." The nursing interventions included "Administer routine medication at dosage and schedule ordered and pm medications for anxiety." 7. Patient C6's MTP dated 3/10/14 identified the problem, "Depressed Mood with Sulcldallty." The nursing interventions were "Special Precautions: Level of Observation Q 15 min checks" and "Administer routine medication at dosage and schedule ordered and pm medication for depression." B. Interview In interview on 3/18/14 at 2:30 p.m., the Director of Nursing acknowledged that the nursing interventions were generic, expected nursing duties and not individualized to the patient. II. Discipline Identification Findings Include: A. Record Review 1. Patients A20 (MTP 3111/14) had Interventions with only the first names of the responsible nursing staff. 2. Patient 82 (MTP 3/12/14) had interventions with only the first names of the responsible nursing staff. 3. Patient 828 (MTP 3/10/14) had interventions with only the first name of the assigned nursing staff. 4. Patient C5 (MTP 3/4/14) had interventions with FORM CMS.2567(02-99) Previous Versions Obsolete ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE B 148 specific to and based on the patient's condition and needs as documented elsewhere in the medical record. Therefore, patients received individualized treatment. II. Discipline Identification: The Medical Director, Director of Pl, CNO, and 04-18-2014 the Director of Social Services reviewed and revised the policy "Treatment Planning Process' to clarify expectations in the following areas: Individualized treatment inventions with a specific purpose and focus are to be clearly described so that treatment interventions are more than just generic monitoring or routine clinical functions, including nursing interventiom Identification of the specific individual(s) responsible for the intervention must include the name and credentials/ discipline. (Attachment E) The revised policy "Treatment Planning Process" was reviewed and approved by the Medical Executive Committee and the Governing Body. 04-18-2014 The CNO and Director of Social Services 04-30-2014 provided training in group settings to all RNs, Therapists/Social Workers, and Activities Therapy staff on the revised "Treatment Planning Process" policy and expectations for adherence to development and documentation of individualized treatment plans for all patients which include the elements of: Individualized treatment inventions for nursing with a specific purpose and focus clearly described so that treatment interventions are more than just generic monitoring or routine clinical functions Identification of the specific individual(s) responsible for the intervention including the name and credentials/ discipline. Attendance at training was tracked by the HR Director who used employee lists and sign in sheets to validate attendance. Any staff members not r"'~"'ivina trainina in aro• m WSXR11 If conllnual/on sheet Page 41 of 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID ~FRVICF~ STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)10 PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 148 Continued From page 41 only the first name of the assigned nursing staff. 5. Patient C6 (MTP 3/10/14) had interventions with only the first name of the assigned nursing staff. 6. Patient C19 (MTP 3/13/14) had interventions with only the first name of the assigned nursing staff. B. Interviews In interview on 3/18/14 at 2:45 p.m., the Director of Nursing stated that the disciplines should have been identified on the MTPs. B 152 482.62(f) SOCIAL SERVICES There must be a director of social services who monitors and evaluates the quality and appropriateness of social services furnished. This Standard is not met as evidenced by: Based on record review and interviews, the Director of Social Services failed to: I. Provide social work assessments that included an evaluation of the current baseline social functioning for 5 of 8 sample patients (A24, 82, C5, C6, and C19). As a result, the treatment teams did not have an assessment of current baseline social functioning for these patients from which treatment interventions and discharge plans could be formulated. (Refer to 8108) JI. Develop and document comprehensive treatment plans to include social work interventions based on the individual social work needs of 8 of 8 sample patients (A20, A24, 82, 828, 838, C5, C6, and C19). This failure resulted FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROS8-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION CATE B 148 sessions were suspended pending receipt of individual training. Understanding of training was validated by post-test. The Director of Pl, CNO, Director of UM, and/or the Director of Social Services are monitoring 100% of treatment plans through attendance and participation in all treatment planning meetings for a period of 90 days to confirm the plans are individualized and include all required elements. (Attachment F) Following this initial focused period of review, the CNO and Director of Behavioral/Social Services will randomly attend treatment team meetings to ensure the process and documentation is maintained per policy. Staff not in compliance will receive retraining by the CNO and/or disciplinary action as appropriate. Aggregated data will be 8152 reported monthly to the Quality Committee and Medical Executive Committee, and quarterly to the Governing Body. Monitoring begun 04-30-2014 & ongoing As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing that these purported documentatio1 issues hampered staff in providing the full rang1 of appropriate treatment: Nurses assessed patients each shift; clinical staff worked with patients on the unit and in activities and groups Nurses administered medications ordered for patients and then assessed to confirm whether patients' condition improved. Nursing and clinical staff responded and provided treatment to each patient each day while determining the effectiveness of treatment and interventions anc whether the patient was improving to be ready for discharge. B 1521: The hospital reviewed and revised 04-30-2014 pertinent policies and forms, provided training to hospital staff, and implemented monitoring to confirm that medical record documentation reflects social work assessment that include evaluation of social functioning. Please see detailed response to B 108. WSXR11 If canllnuallon sheet Page 42 cl 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PL.AN OF CORRECTION (><2) MULTIPLE CONSll'IUCTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: A. BUILDING _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED c 104016 NAME Of PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FUU. REGULATORY OR LSC IDENTIFYING INFORMATION) 8152 Continued From page 42 in absence of specific plans to direct staff in the implementation, evaluation, and revision of care based on individual patient findings. Findings include: A. Record Review 1. Patient A20's MTP dated 3/11/14 Identified the problem, "Psychotic Behavior/Out of Contact with Reality." The only Intervention by social work staff was "Psycho-educational groups related to coping skills." For the problem, "Depressed Mood with Suicidality," the only intervention by social work staff was "Psycho-educational groups related to coping skills." 2. Patient A24's MTP dated 3/4/14 identified the problem, "Psychotic Behavior/Out of Contact with Reality." No social work Interventions were identified to be provided by the social work staff. 3. Patient B2's MTP dated 3/12/14 identified the problem, "Substance Abuse/Dependence." The only intervention by social work staff was "Process Group Therapy (to) leam effective communication." 4. Patient B28's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicldality." No social work Interventions were identified to be provided by the social work staff. 5. Patient 83B's MTP dated 3/7/14 Identified the problem, "Depressed Mood with Suicidality." No social work Interventions were identified to be provided by the social work staff. 6. Patient C5's MTP dated 3/4/14 identified the problem, "Anxiety/Panic Attacks." FORM CMS-2567(02-99) Previous Versions Obsolete 10 PREFIX TAG PROVIDER'S PL.AN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 8152 8 152 II: The Medical Director, Director of Pl, CNO, and the Director of Social Services reviewed and revised the policy "Treatment Planning Process" to clarify expectations in the area of Individualized treatment inventions with a specific purpose and focus to be clearly described so that treatment interventions are more than just generic monitoring or routine clinical functions, including social services interventions. (Attachment E) The revised policy "Treatment Planning Process" was reviewed and approved by the Medical Executive Committee and the Governing Body. (XS) COMPLETION DATE 04-18-2014 04-18-2014 The CNO and Director of Social Services 04-30-2014 provided training in group settings to all Therapists/Social Workers on the revised "Treatment Planning Process" policy and expectations for adherence to development and documentation of individualized treatment plans for all patients, including the elements of individualized social work interventions with a specific purpose and focus clearly described so that treatment interventions are more than just generic monitoring or routine clinical functions. Attendance at training was tracked by the HR Director who used employee lists and sign in sheets to validate attendance. Any staff members not receiving training in group sessions were suspended pending receipt of individual training. Understanding of training was validated by post-test. The Director of Pl, CNO, Director of UM, and/or the Director of Social Services are monitoring 100% of treatment plans through attendance and participation in all treatment planning meetings for a period of 90 days to confirm the plans are individualized and include all required elements. (Attachment F) Following this initial focused period of review, the CNO and Director of Social Services will randomly attend treatment team meetings to confirm the process WSXR11 Monitoring begun 04-30-201~ & ongoing Ir contlnuallon sheet Page 43 of 46 Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVll"'i=~ STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A.BUILDING _ _ _ _ _ __ (X1) PROVIOER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (XJ) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 152 Continued From page 43 "Psycho-educational groups related to sis (signs and symptoms) anxiety." No interventions were identified to be provided by the social work slaff. 7. Patient C6's MTP dated 3/10/14 identified the problem, "Depressed Mood with Sulcidality." No social work interventions were identified to be provided by the social work staff. ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5} COMPLETION DATE 8 152 and documentation is maintained per policy. Additionally, the Social Services Manager is reviewing 10% of admission/discharge charts to assess social work compliance with treatment planning documentation expectations. Staff not in compliance will receive retraining and/or disciplinary action as appropriate. Aggregated data will be reported monthly by the Social Services Manager to the Quality Committee anc Medical Executive Committee, and quarterly to the Governing Body. 8. Patient C19's MTP dated 3/13/14 Identified the problem, "Aggressive/Assaultive Behavior." No social work interventions were identified to be provided by the social work staff. B. Interview In interview on 3/19/14 at 12:30 p.m., the Director of Behavioral Services acknowledged that the social work interventions were generic and not individualized social work-specific interventions. 8 154 482.62(f)(1) SOCIAL SERVICES The director of the social work department or service must have a master's degree from an accredited school of social work or must be qualified by education and experience in the social services needs of the mentally ill. If the director does not hold a master's degree In social work, at least one slaff member must have this qualification. This Standard is not met as evidenced by: Based on interview, the facility failed to provide either a diredor of social work who possessed a master's degree in social work (MSW) or assign an MSW staff to fulfill the duties, fundions and responsibilities of the director of social work related to quality review of social work duties. FORM CMS-2567(02-99) Previous Versions Obsolele 8154 B 154: The CEO and Director of Social Service5 04-04-2014 have revised and formalized the position of Social Services Manager, a part-time job, with the responsibility of supervising the clinical social work functions of assessment and discharge planning through training, consultation, and medical record review. Specific job functions include: Training new/existing social workers in documentation requirements related to completion of psychosocial assessments, treatment planning, and discharge planning through social services group meetings and individual training. Monitoring medical records for thorough completion of assessments, treatment plans, and discharge planning documents. Collecting, aggregating, and reporting performance improvement data related to social services functions. WSXR11 II continuation sheel Page 44 of 4B Printed: 04/04/2014 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMEITT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: A. BUILDING _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8154 Continued From page 44 This resulted in a lack of professionally directed or designed social work services for 4 of 8 sample patients {A24, 82, 828, and 838). Findings include: A. Record Review The 8iopsychosocial Assessments for the following patients (dates in parentheses) revealed that a master's level social worker did not oversee the psychosocial assessments completed by social service staff: Patient A24 (3/5/14), Patient 82 (3/12/14), Patient 828 (1/9/14), and Patient 838 (3/11/14). 8. Staff Interviews 1. During an interview with SW1, a clinical social worker intern (MSW}, on 3/19/14 at 9:00 a.m., she stated that she had no responsibilities for supervising other staff performing social work duties in the hospital. She acknowledged that psychosocial assessments and discharge planning were performed by staff without a masters in social work. 2. During an interview with the Director of Behavioral Services, supervisor of social work services, on 3/18/14 at 9:00, she confirmed that that these social work assessments and discharge planning were performed by staff without a master's degree in social work. She stated that oversight of social work assessments and discharge planning was not provided by a master' s level social worker. She reported that she did not have a degree in social work. 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) B 154 The pm LCSW employee who was previously providing assistance with Pl in social services was formally hired into the Social Services Manager position on 04-06-2014. (X5) COMPLETION DATE 04-06-2014 The new Social Services Manager's orientation 04-11-2014 to the new role was completed internally and a competency assessment was completed by an LCSW at a sister facility in the area. As directed by CMS State Operations Manual 30268, the hospital also provides the basis for disagreeing with this citation that it violated this rule: First, the citation suggests psychosocial assessments and discharge planning must be performed by staff with a master's degree in social work when the rule does not impose such a requirement. Second, the rule requires that (a) the director of the social work department or service must have a master's degree OR (b) the director of social work must be qualified by education and experience in the social services of the mentally ill, and must have a master's-level social worker on staff. Although the Director of Social Work referred to in the citation does not have a master's degree in social work, she has a master's degree in counseling, and she has extensive experience in the social services of the mentally ill: she worked directly with patients for 20 years as a therapist and has also worked in mental health treatment facilities for 15 years in a director position. As the citation acknowledges, the hospital also had a full-time staff member that was a master's level social worker. The hospita therefore submits that it complied with this rule even before it made the personnel changes described above. 3. During a phone Interview on 3/19/14 at 9:10 a.m. with SW2, a contracted LCSW who was FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 II conllnuaUon sheel Page 45 ~r 46 Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ (X1) PROVIDERISUPPUER/CLIA IDENTIFICATION NUMBER: (X3} DATE SURVEY COMPLETED c 104016 NAME OF PROVIDER OR SUPPLIER RIVER POINT BEHAVIORAL HEALTH (X4)1D PRE AX TAG 04/04/2014 FORM APPROVED 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FlA.L REGULATORY OR LSC IDENTIFYING INFORMATION) B 154 Continued From page 45 assigned to perform quality assurance activities for the social services department, she stated that she did not review the quality of lhe psychosocial assessments or discharge planning performed by staff without a master's degree in social work. She stated that she reviewed quantitative Information (timeliness of assessments and sessions, completeness of documentation, etc.) but that staff without master's degrees in social work performed qualitative peer reviews for each other. She stated that she did not directly supervise the work of any staff at the facility. ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} (lt5) COMPLETION D...TE B 154 C. Document review A review of the document "Employee Listing of All Therapists for River Point Behavloral as of March 18, 2014" presented by the facility of all staff providing social work services at the facility indicated that there was only one full-time staff (SW1) who was providing social work services. FORM CMS-2567(02-99) Previous Versions Obsolete WSXR11 II conllnualion sheel Page 46 of 46 TABLE OF ATTACHMENTS A-Social Functioning Measure Tracking Sheet B- Policy 140 - Comprehensive Needs Assessment C- Psychiatric Evaluation Measure Tracking Sheet D- Template Treatment Team Attendance E- Policy 760 - Treatment Planning Process F- Treatment Planning Process Measures Tracking Sheet G-Progress Notes Documenting the Active treatment in Progress Notes Measure Tracking Sheet H-Alternative Therapy Interventions Measures Tracking Sheet I- Policy 222 - Alternative Treatment Interventions J- Policy 560 - Laboratory Work K- Laboratory Measures Tracking Sheet L- Revised excerpt from Medical Staff Rules and Regulations on Discharge Summary expectations M- Discharge Summary Measure Tracking Sheet Attachment - A Psychosocial Assessment Form Tracker The Social Services Manager/designee is to monitor 100% of Psychosocial Assessments weekly for a period of 90 days to confirm that all Psychosocial Assessments are completed in a timely fashion and include an evaluation of social functioning level. Following the initial review, if compliance has been achieved at 90%, a random sample of 30% of psychosocial assessments will be reviewed each week for another six months. Staff not in compliance will receive retraining by the Social Services Manager and/or disciplinary action as appropriate. The Social Services Manager is responsible for aggregating the data and reporting it monthly to the Quality Committee, Medical Executive Committee, and quarterly to the Governing Body. Check box if compliant Date=----------------== MR# Completed within48 hours Evaluation of social function level Utilization of social functioning level in treatment plan Reviewer:-------------------- Utilization of social functioning level in Discharge plan Totals Compliant Comments for n o n - c o m p l i a n c e : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Attachment - B RI VER POI NT BEHAVIORAL HEAL TH Page 1 of 4 Effective: 12/99 Last Reviewed: 04/2014 COMPREHENSIVE NEEDS ASSESSMENT POLICY: 140 All patients admitted to the facility will receive a thorough assessment and evaluation to determine the most appropriate level of care, without regard to gender, age, color, race, creed, sexual orientation, ancestry, financial ability, national origin or disability. All assessments are documented in writing in the patient's medical record. PROCEDURE: DOES WHAT Evaluation & Referral (E&R)/ Staff 1. Initiates Needs Assessment process to determine the treatment needs of the client/patient. 2. Obtains the following information on initial inquiry: a. Information about the client/patients current condition/situation, including safety; b. Type of service the client/patient is seeking; c. Who referred the client/patient; d. Appropriate disposition. 3. On evaluation/admission documents initial assessment information on Intake Needs Assessment Tool. This information will include, but is not limited to: a. Demographic information. b. Presenting problem including precipitating factors. c. Chief complaint with emphasis on why the client/patient has come for the assessment/admission. d. Psychiatric and Substance Abuse History. e. Communicable Disease, Medical/Physical Screening f. Suicidal/Homicidal Risk Assessment. Includes an assessment of suicidal/homicidal risk and protective factors. g. Mental Status Exam. h. Social, Relational, Familial, Educational, Occupational, Financial, and/or Legal Stressors. i. Sexually aggression or victimization behavior history j. Trauma history k. Current health problems including sleep and appetite problems. Revised: 04/05, 03/08, 05/08, 05/09, 09/09 12/12, 7/13, 02/14, 04/14 Function: Assessment of the Patient Attachment - B RI VER POI NT BEHAVIORAL HEAL TH Page 2 of 4 Effective: 12/99 Last Reviewed: 04/2014 COMPREHENSIVE NEEDS ASSESSMENT 140 DOES WHAT E&R Staff 4. Evaluation to determine TB exposure/symptoms. a. If exposure determined, will send out for immediate medical attention. b. Admission Disposition/Level of Care Determination and Rationalization. RN 5. Completes the Nursing Assessment within eight (8) hours of admission. The following sections may be delegated to an LPN or MHT to complete: a. Contraband check. b. Vital Signs (including height and weight) and BAL (if trained/competent) c. Orients client/patient to the unit and completes the patient orientation checklist. RN 6. Reviews the previous assessments and validates the information with the patient/family. RN 7. Completes the Nursing Assessment collecting the following information: a. Body/Skin check including any signs of injuries/body markings (with witness present) b. Allergies to food/medicine/environment c. Medications client/patient is currently taking to include OTC (documented on Medication Reconciliation Form). d. Medical History/Examination (HEENT, cardiopulmonary, endocrine, neurological, skin, gastrointestinal, genitourinary, musculoskeletal, sexuality/reproduction, neurological, medical/surgical hospitalizations, sleep patterns/disturbances, appetite disturbances). e. AIMS test if patient taking antipsychotic medications. f. Educational needs/learning barriers. g. Fall Risk Assessment h Nutritional Screening i. Functional Screening Revised: 04/05, 03/08, 05/08, 05/09, 09/09 12/12, 7/13, 02/14, 04/14 Function: Assessment of the Patient Attachment - B RI VER POI NT BEHAVIORAL HEAL TH Page 3 of 4 Effective: 12/99 Last Reviewed: 04/2014 140 COMPREHENSIVE NEEDS ASSESSMENT DOES WHAT j.. Pain Assessment k. Restraint/Seclusion Assessment I. Summary of Findings WHO RN RN Therapist/SW 8. If a nurse is unable to complete the assessment of the client/patient due to issues such as psychosis, refusal, etc., the nurse will: a. Document on the assessment form and in the progress notes the reason for an incomplete assessment. Make a reasonable attempt to collect information from family/ significant others until client/patient is able to answer questions. b. Report to the incoming shift the status of the Nursing Assessment and the reason. c. RNs will continue to attempt to complete the assessment every shift and document attempts until completed 9 Completes Psychosocial Assessment with information from the patient, famil and/or si nificant others The a!essment will cont;i~ th~,~following,,info;~;ti~n: ,, , a. Family/significant other perception regarding reason for admission. Psychiatric/substance abuse history, including prior treatment and patterns of drug/alcohol usage Pertinent developmental issues. b. c. Family environment (spouse/parent, siblings, sex, age, marital status, relationship to patient, where living, education and occupation). d. Family history of psychiatric/substance abuse e. Living Arrangements f. Vocational History g. Educational History h. Military History i. Spiritual/Cultural Assessment j. Daily Living Patterns k. Social Functioning Level - baseline and current 1. Sexual History m. Trauma/Abuse History (victim and perpetration) IU fJ •. ·llfl~1'!4~,~9'1tirl{ Revised: 04/05, 03/08, 05/08, 05/09, 09/09 12/12, 7/13, 02/14, 04/14 Function: Assessment of the Patient Attachment - B RI VER POI NT BEHAVIORAL HEAL TH Page 4 of 4 Effective: 12/99 Last Reviewed: 04/2014 COMPREHENSIVE NEEDS ASSESSMENT WHO Therapist/SW DOES WHAT n. o. p. q. r. s. Therapist/SW 140 10. Financial Concerns Patient strengths/weaknesses/resources available Initial needs assessment High risk issues for treatment and discharge planning Clinical Impressions Recommendations related to anticipated role of social worker/therapist in treatment, anticipated role of family/guardian in treatment, and anticipated role of therapist/social worker in discharge planning. In the event the client/patient is re-admitted within a thirty (30) day period, an Updated Psychosocial will be obtained. Activity/Recreation Therapist-Certified 11. Therapist 12. Physician 13. llitff