PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER '! 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH I c B. WING _ _ _ _ _ _ _ _ __ 104016 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ _ __ JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I l ID PREFIX TAG I I i AOOO A 000 I INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ! (XS) COMPLETION DATE I I An unannounced substantial allegation complaint survey, CCR#2014000954, was conducted at River Point Behavioral Health, on March 17-19, 2014. River Point Behavioral Health is not in compliance with the Federal Regulations at 42CFR Part 482, i Requirements for Acute Care Hospitals. A 144 ! 482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE 1 1. SETTING I I., The patient has the right to receive care in a safe ! setting. ·1 This STANDARD is not met as evidenced by: Based on observations, interviews and record reviews, the facility failed to provide care in an emotionally safe environment to promote respect, dignity and comfort on 2 (Emergency Stabilization and North) of 3 units. The Findings Include: 1. During the initial observation of the facility on , 3/17/2014 at 10:00 AM, an interview with the I Director of Nursing (DON) revealed the facility ' consisted of 3 separate units. The North Wing I has 38 beds and houses male and female . patients for chemical dependency and psych. The i Emergency Stabilization Unit (ESU) has 26 beds housing both male and female patients. The I Older Adult Unit (OAU) has 28 beds that houses male and female adults over 55 years of age. The I DON stated the facility used cots for overflow · patients, but the staff tries to arrange discharges throughout the day, so they can empty beds and not have to use cots. I 1 , I I I i LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 04/07/2014 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 Facility ID: HL 104016 If continuation sheet Page 1 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH ! c B. WING _ _ _ _ _ _ _ __ 104016 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A BUILDING _ _ _ _ _ _ __ (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) '1 I i A 144 Continued From page 1 The unit observations on 3/17/2014 at 10:00 AM revealed the North Wing's census was 42. There are cloth mattresses with vinyl coverings observed on the floor in 3 patient bed rooms. The mattresses are observed without sheets and pillows. ID PREFIX TAG I , 1 \ PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE I A 1441 I I 1. I An interview with the DON at 10:00 AM confirmed I the North Wing Unit is over capacity, despite I already having 3 discharges this morning. An I observation of the ESU revealed the census was 31 with 7 pending discharges. There are 7 mattresses observed in a closet touching each other. An interview with the DON at 1O: 15 AM revealed the mattresses on the floor (previously called cots) are for the overflow patients. An observation of the OAU on 3/17/14 at 10:35 AM revealed the census was 27. There are 28 beds on the unit. One patient room is observed with 3 beds and 1 mattress on the floor; there were no sheets or pillows observed on the mattress on the floor. 2. An observation of lunch in the ESU on 3/18/14 at 12:10 PM revealed the room was not large enough to accommodate the 23 patients who were attempting to eat lunch. The room is observed with 4 round tables. Two patients are observed placing their food trays on the floor to add salt and pepper. These 2 patients then placed the lunch trays in their laps to eat. There were 5 patients observed eating lunch while holding their food plates in their laps, with their drinks on the floor. Two patients were observed standing at a counter eating. I An observation of a second activity room located I within the ESU on the opposite side of the nursing / FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 Facility ID: HL 104016 If continuation sheet Page 2 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID ,I PREFIX TAG (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I I ID PREFIX TAG I I i A 144 I Continued From page 2 , station on 3/18/14 at 12: 15 PM that was used for ' patients during meal times revealed 4 patients walking back and forth waiting for service and lunch. The ESU staff did not have enough juices or plastic ware to accommodate the patients in the units. The patients observed in the second activity room voiced concern to the staff about the possibility of not having enough food to go around. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ! (XS) COMPLETION DATE I A 144 I I' The 4 patients in the second activity room walked into the main activity room and stood around the doorway until they were served. The ESU staff were observed apologizing to patients for reaching over them while they were eating, "We have some tight quarters here, I am just trying to make sure everyone gets something to eat and drink. We have called dietary to get more juice, so please be patient with me; everyone will get something to drink." An interview with the DON on 3/18/2014 at 12:35 PM revealed she acknowledged the facility is aware of the dining situation in the ESU unit. The facility is planning on moving the activity room to a different location that is larger and can accommodate the patients in the area. The DON was informed of the Surveyors' concerns regarding patients putting the Styrofoam meal containers and drinks on the floor, while other patients and staff are walking around and over them. The DON was also asked what the facility will do in case of an emergency in the dining area during lunch. The DON stated the staff does a great job controlling the patients in the area during meal time, and the facility has not had any incidents. I . 1 j I' I j I I j 3. A review of the facility's policy and procedures I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 Facility ID: HL 104016 If continuation sheet Page 3 of 13 PRINTED: 10/05/2015 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH i c B. WING _ _ _ _ _ _ _ __ 104016 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I, I ID PREFIX TAG I A 144 Continued From page 3 for Patient Rights with an effective date of 12/1999 and a last review date of 2/2014 revealed patients have the right to quality : treatment. Each patient shall have treatment I suited to his or her own needs, which shall be i administered skillfully, safely, and humanely. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE A 144 I 14. An interview with the Infection ' Control/Performance Improvement Director and : Compliance Officer on 3/17/2014 at 1010 AM ' revealed the use of mattresses on the floor is better than throwing a blanket on the floor. She stated the mattresses are wiped down daily, but the facility did not have a policy and procedure related to the cleaning and use of the mattresses. A 148 482.13(d)(2) PATIENT RIGHTS: ACCESS TO MEDICAL RECORD A 148 The patient has the right to access information contained in his or her clinical records within a reasonable time frame. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits. I This STANDARD is not met as evidenced by: ! Based on record reviews and staff interviews, the [ facility failed to permit 1 (#7) of 11 patients the right to review her medical record. Patient #7 requested to review her medical record on [ 2/21/14 and was informed by a caregiver that this was only permitted after she was discharged. ·j ·I I The Findings Include: I 1. Medical record review revealed Patient #7 was I admitted to the facility on 2/17 /14 under a Baker I I FORM CMS-2567(02-99) Previous Versions Obsolete I Event ID:6WA911 Facility ID: HL 104016 If continuation sheet Page 4 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ I ID PREFIX TAG I I I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE I' I A 148, Continued From page 4 I Act/involuntary admission, with diagnoses to · include multiple psychiatric disorders. Nursing I documentation on 2/23/14 revealed Patient #7 ' requested to see her medical record. The , caregiver informed Patient #7 of the facility's I policy; that she can only see the medical record I after she is discharged. i Interview with the Director of Risk Management in Medical Records on 3/18/13 at 11 :30 AM i revealed a patient may review their medical I record unless there is a restriction placed by the physician. She stated patients have the right to I i access their medical records. The Director of Risk Management stated she was unaware of the I request on 2/23/14 for Patient #7 to review her , medical record, and that a staff person declined i that request. The Risk Manager stated if they I want a copy after discharge, then that is a i different procedure. A454 482.24{c)(1) CONTENT OF RECORD: ORDERS DATED & SIGNED I, i I j A454 All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is I responsible for the care of the patient only if such . a practitioner is acting in accordance with State I law, including scope-of-practice laws, hospital , policies, and medical staff bylaws, rules, and regulations. j' This STANDARD is not met as evidenced by: Based on record reviews and interviews, the facility failed to ensure telephone orders for restraints were authenticated by a physician for 2 (J#13 and J#14) of 3 patients. I I I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 I Facility ID: HL 104016 If continuation sheet Page 5 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER A. B U I L D I N G - - - - - - - - NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH i c B. WING _ _ _ _ _ _ _ _ __ 104016 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I I ID PREFIX TAG ! i PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE I I A 454 i Continued From page 5 I : The Findings Include: A454 , 1). A medical record review for Patient #J 13 · revealed that she was involuntarily admitted into the facility on 1/23/2014. On 2/2/2014, Patient #J13 was observed banging and kicking the door , to the nurses' station while threatening staff. An . emergency intervention telephone order was received at 12: 07 AM for .physical restraint, seclusion, and medication restraint. The maximum time ordered for this intervention is 4 hours. The criterion for release is that Patient #J14 must calm down. The physical restraint time is documented at one minute from 12:07 AM to 12:08 AM. Seclusion was initiated at 12:08 AM. Patient #J 13 was chemically restrained using Prolixin 5mg IM for psychosis and Benadryl 50mg IM for anxiety. Patient #J13's seclusion ended at 1:05 AM. An observation of the medical record revealed that the restraint/seclusion telephone orders have not been authenticated. 2). A medical record review for Patient #J14 reveals he was involuntarily admitted into the facility on 1/17/14. On 1/20/2014 at 5:04 AM, Patient #J14 was observed cursing, yelling, and ' threatening other patients and staff. Emergency I intervention orders for restraint, chemical restraint ' and seclusion was initiated via a telephone order, I for a maximum time of 4 hours. The ordered use of chemical restraint includes Haldol 5mg intramuscularly (IM) for psychosis and Ativan1 mg IM for agitation. The clinical justification is that : Patient #J 14 was a danger to others. Patient I #J14 was in seclusion from 5:04 AM to 5:21 AM. · An observation of the medical record reveals that the restraint/seclusion telephone orders have not I I been authenticated. ·1 , 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA911 Facility ID: HL 104016 If continuation sheet Page 6 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID I PREFIX ! TAG , (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG A 454 Continued From page 6 : 3). An interview with the Director of Nursing ! (DON) on 3/18/14 at 3:46 PM confirmed after ' reviewing the medical record that the Physician never signed the telephone order for the Physical and Chemical restraint, or Seclusion. It is a , facility's expectation that physicians sign telephone orders for all restraints and seclusion. When asked, the DON revealed that she would try to get the physicians on the telephone to talk , to this Surveyor regarding signing telephone I orders. i (XS) COMPLETION DATE A454[ ':I ! , 4). An interview with the Director of Clinical Services on 3/19/2014 at 12:20 PM while reviewing the medical records for Patients #J13 and #J14 reveals that physicians are supposed to sign telephone orders to include restraint/seclusion orders within 48 hours of order initiation. The Director of Clinical Services confirmed that the restraint/seclusion orders have : not been signed for either patient. She stated this ! has been an ongoing facility issue. Physicians are I aware that they are supposed to sign the telephone orders in 48 hours, but they just do not I do it. 1 I ! 5). An interview with the DON on 3/19/2014 at 1:30 PM reveals that none of the physicians who are identified as not signing the I restraint/seclusion orders are in the facility at the , present time. The DON was asked by this I Surveyor if it was possible to talk to one of the I physicians by phone since they were not in the facility. The DON stated that both physicians have a daytime practice with patients, so she was unsure if they would be available at this time. The •I DON was given this Surveyor's cell phone i number and asked to have the physician call , back. At 2:15 PM, the DON attempted to I 1 ! FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 i Facility ID: HL 104016 If continuation sheet Page 7 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID I PREFIX ! TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A BUILDING _ _ _ _ _ _ __ JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I A 454 · Continued From page 7 I follow-up to see if a physician had made contact with this Surveyor. The DON stated that she would call again and leave another message to the physician to call this Surveyor. There was no call received by this Surveyor from a physician regarding this matter. I 1. ID I p~!~IX I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE ! I A4541 I I I 6). A review of the policy and procedures for telephone orders with an effective date of 11/2004 and a last revised date of 6/2009 reveals that physician telephone orders must be authenticated within 48 hours. If the practitioner is off duty, then another practitioner who is responsible for the patient's care can authenticate the verbal order of I the ordering practitioner. A820 482.43(c)(3), (5) IMPLEMENTATION OF A DISCHARGE PLAN I A820 (3) The hospital must arrange for the initial implementation of the patient's discharge plan. (5) As needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care. This STANDARD is not met as evidenced by: Based on medical record reviews, patient and staff interviews, the facility failed to ensure that patients and/or family were involved in the discharge planning process for 6 of 11 sampled . patients (#1,#2,#4,#5,#6,#11 ). I I 1 The Findings Include: 1 i Review of the medical record for Patient #1 . I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 Facility ID: HL 104016 If continuation sheet Page 8 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX : TAG ! (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I \ ID PREFIX TAG I i A 820 i Continued From page 8 I revealed she was admitted to the facility on 3/9/14. Her discharge plan was to return to her previous living arrangement, and the patient , signature was dated 3/13/14. On 3/17/14, the ! patient was still observed to be in the facility. Interview with Patient #1 on 3/17/14 at 10:15 AM revealed she was admitted last Sunday and she is leaving with her fiance and will be staying at the . Emerson Inn Motel, because she is homeless. i She stated she has already signed her discharge I forms a couple of days ago and they will give her · prescriptions for her medication when she is discharged. I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE I 1 I A820 I I I j I I ; Interview with Patient #2 on 3/17/14 at 10:25 AM i revealed he was admitted last Tuesday. He stated he was being discharged today to his mother's care. I Review of the medical record for Patient #2 ! revealed he was admitted on 3/11/14 and his final discharge papers were signed on 3/14/14. His final discharge forms included statements that his current medication list was given and explained. A copy of the Discharge Safety Plan was given and reviewed. A copy of all discharge instruction was given and reviewed. Patient's personal belongings from bedroom, belongings room and safe have been returned. Educated and provided hand-out on "Facts about Suicide and Depression" to patient and significant other/guardian, including "Black Box Warning for SSRI." I I Review of the medical record for Patient #4 revealed she was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 i Facility ID: HL 104016 If continuation sheet Page 9 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID I PREFIX TAG I (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I ! (XS) COMPLETION DATE ' A 820 I Continued From page 9 A8201 · 3/4/14. Her final discharge papers were signed on i 3/7/14 to return to previous living arrangement. I Patient #4 was observed on 3/17/14 to still be in • the facility. I I i An interview was conducted with the Director of Quality on 3/17/14 at 2:30 PM. She was asked to review the medical records of Patient #2 and Patient #4, to explain why the discharge papers were filled out in advance of the patients' discharge and she stated she did not know. They will have to be signed again on discharge, so I don't know why they were already signed. Interview with the Charge Nurse on 3/18/14 at 9:30 AM revealed her part of discharge planning starts the day of discharge. The therapist does her portion a little before the discharge. The patient is supposed to sign the forms when they are discharged. Recently, we have been having the patient sign all their forms at their first team meeting, but I don't know the reason. I think it is good for patients to sign them when they are competent and that isn't always at admission. Observation of the treatment team meeting for Patient #4 was conducted on 3/18/14 at 10:00 AM. The Medical Director left before the meeting began; the Charge Nurse and Therapist were present along with Patient #4. The discussion was about the Assisted Living Facility not wanting Patient #4 to return to the facility. I I Interview with the Therapist on 3/18/14 at 10:55 AM revealed they are trying to prepare Patient #4 . for discharge. She stated we meet with patients FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 Facility ID: HL 104016 If continuation sheet Page 1O of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED I A 820 Continued From page 10 every 7 days to see if they are meeting goals. She revealed she is the discharge planner. We discuss all paperwork within 48 hours of . admission and patients are instructed to sign their discharge papers at that time. If things change, then we put a line through them on the form. The patient doesn't re-sign the changes. Discharge planning starts at admission. If things change, then we put a line through them, but no, the , patient is not asked to re-sign. When asked how the facility documents, if the patient is advised of the changes or involved in the decision, she stated I guess we don't. ID PREFIX TAG I I ! PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE A8201 1 Review of the medical record for Patient #5 revealed she was admitted to the facility on ' 3/24/13 and her discharge papers were signed on admission. The patient was discharged from the facility on 4/5/13. Review of the medical record for Patient #6 revealed she was admitted to the facility on , 4/9/13 and her discharge papers were signed on admission. The patient was discharged from the i facility on 4/15/13. I I I I Observation of the discharge process for Patient #11 was conducted on 3/18/14 at 11:20 AM with the Therapist. Patient #11 's discharge planning papers were blank. The Therapist stated she wanted to discuss her discharge plan. She asked the patient for her address that she would be going to, and a current telephone number for contact. She asked who would be picking her up and the patient stated her boyfriend. The Therapist stated she needed the patient to write FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 Facility ID: HL 104016 If continuation sheet Page 11 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMS NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX , I TAG (X3) DATE SURVEY COMPLETED JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG I I I A 820 Continued From page 11 · down some wellness goals on her form and ! suggested that she write down that she was going • to start running for stress relief. The Therapist did not ask the patient if she was a runner or wanted I I to start running. The Therapist stated there is I ' supposed to be a family session prior to I discharge, and was the patient interested in doing . that over the telephone. The patient said no. The patient was told to sign the discharge plan and initial the safety statements. The Therapist stated she would print off a list of available services in the patient's area and she would give her a copy of everything she signed, as she was going out the door. The patient got up and left the room. 1 1 'I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ! i (XS) COMPLETION DATE A8201 I I I I I I Interview with the Therapist on 3/18/14 at 11 :30 AM revealed she met with Patient #11 once during treatment team, but her discharge papers were not filled out and I haven't seen her since. This is only her third day of admission. She revealed she does not do any follow-up with patients after their discharge. I have some patients who call me to talk, but I don't contact any patients. Interview with the Director of Social Services on 3/18/14 at 3:30 PM revealed discharge planning starts when the patient is admitted. We have to initiate things within 72 hours. We have to continually update the plan, because it changes frequently. The therapist and patient develop the discharge plan with oversight from the psychiatrist or nurse. Patients sign their discharge papers in the beginning. We expect things to change and then we add to the form. The patient isn't asked to re-sign papers. My expectation would be for the patient to sign the final review of papers on discharge. I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 Facility ID: HL 104016 If continuation sheet Page 12 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 NAME OF PROVIDER OR SUPPLIER ! 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH II c B. WING _ _ _ _ _ _ _ _ __ 104016 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. B U I L D I N G - - - - - - - - JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG I I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE \ A 820 Continued From page 12 · Review of Patient #2's discharge papers revealed the patient signed and dated the final .1 I ! discharge forms on 3/14/14 and wasn't ' discharged until 3/17/14. She stated the patient should not have been asked to sign his final discharge papers on 3/14/14. She stated they recently updated their forms and tried to improve I the process, and it isn't being done as it was · intended. j FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6WA911 A8201 Facility ID: HL 104016 If continuation sheet Page 13 of 13 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. B U I L D I N G - - - - - - - - - JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 000 INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE 8000 An unannounced complaint survey was conducted by federal consulting surveyors in conjunction with Florida state surveyors from 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 REOS FOR PSYCH HOSPITALS B 103 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 services in the institution. This CONDITION is not met as evidenced by: Based on observation, record review, and interview the facility failed to: 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 addition, 6 of 8 sample patients (A20, A24, 82, 828, CS, 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) LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 1 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: 104016 OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B.WING NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 103 Continued From page 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 103 II. 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. (Refer to 8125 I) Ill. 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. (Refer to B 125 11) 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 B 108 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 2 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 108 Continued From page 2 resource contacts as well as a social history. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 108 This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to 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. 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 B.A. [Baker Act] for psychosis. Pt denies any and all form 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 3 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED 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 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 108 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 developing an effective and meaningful treatment plan. 3. Patient C5 The "Psychosocial Assessment" for Patient C5 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. 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 C6 (3/10/14) and Patient C19 (3/13/14). B. Staff Interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 4 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 108 Continued From page 4 During an interview 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. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 108 C. Policy Review A review of the facility policy "Comprehensive Needs Assessment" "effective 12/99, 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 B 110 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 (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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 5 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B.WING 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 110 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 110 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 1. Patient CS a. Patient CS was a 32 year-old admitted to the "older adult unit" on 3/10/14 because of "basically wanting to kill [him/herself] 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 CS 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." b. The "Second Opinion Psychiatric Evaluation" dated 3/12/14 stated that Patient CS "appears to have a developmental disability, as well as a diagnosis of psychosis." This opinion stated "[s/he] appears to have learning disabilities" and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 6 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMS NO. 0938-0391 A. BUILDING _ _ _ _ _ _ __ c B. WING _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH {X4) ID PREFIX TAG {X3) DATE SURVEY COMPLETED {X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 110 Continued From page 6 "[his/her] cognitive functioning appears to be consistent with borderline intelligence/mild mental retardation." Diagnoses included "rule out borderline intelligence/mild mental retardation." PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 11 O c. The "Psychosocial Assessment" dated 3/17/14 at 4:25 p.m. ("replacement from 3/12/14") stated that Patient C6's "Developmental History" included "special ed [education] classes" and "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 ETOH [alcohol]." d. The "Physician Orders" dated 3/10/14 at 10:00 a.m. stated "Librium 25 mg [milligrams] po [orally) tid [three times per day) pm [as needed] for W /D [withdrawal)." 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 3/18/14 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 C 19 "believes that [s/he] is currently in Michigan" and [her/his] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 7 of 48 PAINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMS NO 0938-0391 A. B U I L D I N G - - - - - - - - c B.WING 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 110 Continued From page 7 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 cognitively intact to answer questions like that [substance abuse history]." "The patient is alert and oriented times zero." The only diagnosis was "psychosis, NOS." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION OATE B 110 b. The "Consultation" assessment for Patient C19 by the medical provider on 3/13/14 stated "[s/he appears demented" and that medications included Aricept and Namenda. The "Assessment/Plan" included "Alzheimer's disease." c. The MPT dated 3/13/14 stated the only diagnosis was "Psychosis, NOS." There were no problems, goals, or interventions that considered Patient CS's reported dementia. B. Staff Interview 1. During an interview with MD 4, attending psychiatrist for Patient CS, he stated that Patient CS'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 CS 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 [historical] diagnosis rather than change them [diagnoses]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 8 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG B 110 Continued From page 8 B 110 "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 C19. The Medical Director stated "until the discharge summary is done, it doesn't require a diagnosis." B 118 482.61 (c)(1) TREATMENT PLAN B 118 (XS) COMPLETION DATE 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, A24, 82, 828, C6, 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. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 9 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 9 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 118 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. Patient A24's initial MTP dated 3/4/14 did not have a psychiatrist signature to indicate physician direction or participation in the establishment of an individualized treatment plan. 3. Patient B2's initial MTP dated 3/12/14 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 C6'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 10:00 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 1O of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 1O PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 118 asked the patient about his/her depression and chronic headaches. RN2 and Therapist2 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 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." RN1 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 3/18/14, 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 11 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OM8 NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ COMPLETED c B. WING _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 118 Continued From page 11 Monday-Fridayfrom 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. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE 8 118 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 Data sheet, dated 3/18/14 MD6 had one patient on Clinical Manager 2's unit. 3. In interview on 3/18/14 at 11: 00 a.m., Patient 828 stated that his/her physician, MD2, came to see her at night after 8 p.m. When 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 3/17/14, 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 8 121 The written plan must include short-term and long range goals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 12 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 121 Continued From page 12 This STANDARD is not met as evidenced by: Based on record review and interview, 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, CS, C6, and C19). In addition, 5 of 8 active sample patients (A20, 82, 828, 838 and C6) 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. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 121 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 will 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." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 13 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 121 Continued From page 13 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 121 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." 5. Patient 838 was admitted on 3/7/14. The MTP dated 3/7/14, 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 CS 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." 7. Patient C6 was admitted on 3/10/14. The MTP dated 3/10/14, for the problem "Depressed Mood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 14 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4} ID PREFIX TAG (X3) DATE SURVEY COMPLETED JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 121 Continued From page 14 with Suicidality" had the short-term goal "Patient will report any suicidal thoughts/impulses/urges to staff before acting on them." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 121 8. 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." B. 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 )(iii) TREATMENT PLAN B 122 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, 828, 838, CS, C6, 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 15 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 122 Continued From page 15 treatment needed. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS} COMPLETION DATE B 122 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 Suicidality," 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 Observation 15 min checks," (Psychiatrist) "Order medication and titrate dosage as needed" and "Activity Therapy Group to (increase) coping skills." 3. Patient B2'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 pm (as needed) medication for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 16 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION 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 depression" and (Psychiatrist) "Order medication and titrate dosage as needed." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5} COMPLETION DATE B 122 5. Patient 838's MTP dated 3/7/14 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 s/s (signs and symptoms) anxiety." 7. Patient C6's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality." Interventions included (Nursing) "Special 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." B. Interview 1. In interview on 3/18/14 at 2:30 p.m., the Director of Nursing acknowledged that the nursing interventions were generic, expected FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 17 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ c B.WJNG 104016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG 03/19/2014 JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 122 Continued From page 17 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 122 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 B 123 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. 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 18 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 123 Continued From page 18 with only the first names of staff members without identifying the discipline for the Psychiatrist, Nursing staff and Social Worker/Therapist. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 123 4. Patient 828 (MTP 3/10/14) had interventions with only the first name of the assigned nursing staff. 5. Patient 838 (MTP 3/7/14) had interventions with only the first name of the assigned Social Worker/Therapist. 6. Patient CS (MTP 3/4/14) had interventions with only the first name of the assigned Psychiatrist and Nurse. 7. Patient C6 (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. B. Interviews 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 3/18/14 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 B 125 The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 19 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION 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 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 125 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 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. Findings include: I. Failure to ensure adequate assessment of the readiness for discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL 104016 If continuation sheet Page 20 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH PREFIX TAG c B. WING _ _ _ _ _ _ _ __ 104016 (X4) ID (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 20 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 125 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, [s/he] 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 disability for approximately eight years and had become distressed due to other recent financial losses. Patient C25 stated [s/he] had felt "up and down all day" and would sometimes "get down about being disabled." The friend advised Patient C25 that by telling the VA that [s/he] 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 and told the caller that [s/he] "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 stated that [s/he] believed a law enforcement officer was listening in on the conversation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 21 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED {X2) MULTIPLE CONSTRUCTION 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 Patient C25 stated that a "swat team" entered the dental office and placed him custody. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 125 Patient C25 stated that [s/he] had not been depressed or suicidal during the week prior to admission. Patient C25 stated that [s/he] 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 3/6/14. Patient C25 stated that [s/he] did not feel depressed but felt "at their [the facility's] mercy" and had to take the medication or [s/he] 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." B. 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 [s/he] was very depressed and was thinking about 'ending it all' ... [Patient C25] stated [s/he] was 'overwhelmed, depressed' and sometimes [s/he] felt 'life is not worth living.'" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 22 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B.WING 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION 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 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 125 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 S/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 ideations." 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 [s/he] was overwhelmed. [S/he] felt like life was not worth living. 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] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 23 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION 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 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] lower 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." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 125 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." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 24 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ (X3) DATE SURVEY COMPLETED c 104016 B.WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG 03/19/2014 JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 24 6. The progress notes by the psychiatrist stated the following: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 125 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 time) 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. 7. The progress notes by the nursing staff stated the following: a. The "24-hour RN Progress Note & Once a Day Suicide Risk Assessment" dated 3/14/14 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 "anxious & concerned about the events surrounding [her/his] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 25 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 25 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE • DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 125 Baker Act [involuntary hospitalization]." 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 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 "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], ANH [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, isolative, or guarded" but was not "verbalizing suicidal ideations or a desire to harm self," "experiencing command hallucinations to harm self," or "verbalizing hopelessness, helplessness, anxiety, or depressed mood." Additionally, the note added that Patient C25 was "observed ... participating in treatment. Pt is very irritated [with] being admitted here." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 26 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - 104016 c B.WING 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION 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 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION 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 [s/he] was feeling suicidal...[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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 27 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 27 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 irritability 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 [s/he] was not going to harm [her/himself]. MD 3 stated 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. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 125 2. During an interview 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. II. Treatment based on individual patient need PatientA24 was a 31 year-old admitted 3/4/14 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 28 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - 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 with a diagnosis of "Schizophrenia, paranoid, chronic with acute exacerbation." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 125 A. Observations 1. Observations on 3/17/14 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, Patient A24 was admitted because of psychosis and threatening [his/her] mother. 2. Review of Patient A24's group notes for 3/6/14-3/17/14 (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, there were no specific interventions for this patient's specialized needs documented in the treatment plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 29 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 29 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) 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 PatientA24 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 been 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." 3. The "Consultation" [medical history and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 30 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B.WING 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION 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 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." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 125 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 14.0-18.0], 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/ml]. A review of the urine "Drug Panel" indicated a negative result for all substances measured FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 31 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMS NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 125 Continued From page 31 except a positive result for opiate. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION OATE B 125 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 abnormal 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 B 133 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 failure 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 Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 32 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. BUILDING _ _ _ _ _ _ __ c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 133 Continued From page 32 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 133 A. Record review Patient 02 (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 B 135 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 (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. Findings include: A. Record Review Patient 03 (date of discharge, 1/1/14) and Patient 05 (date of discharge, 1/2/14) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 33 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMS NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED 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 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE 8135 1. The sections entitled "Hospital Course and Prognosis" were generic and almost identical for both Patient 03 and 05 even though Patient 03 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. While receiving treatment, [s/he] 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 [her/his] 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 in [his/her] symptoms. [S/he] was discharged with no acute safety issues noted." 3. For Patient 05, the "Hospital Course and Prognosis" section was as follows: "The patient was admitted to the inpatient unit. While receiving treatment, [s/he] 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 34 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 135 Continued From page 34 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 135 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 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 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." 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: FOAM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXA11 Facility ID: HL 104016 If continuation sheet Page 35 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B.WING 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 144 Continued From page 35 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE 8144 I. Ensure that 2 of 8 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 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, C6, 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 8118) Ill. Provide Master Treatment Plans that included short-term goals stated in measureable, patient FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 36 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 144 Continued From page 36 focused terms for 8 of 8 active sample patients (A20, A24, 82, 828, 838, CS, C6, and C19). In addition, 5 of 8 active sample patients (A20, 82, 828, 838, and C6) 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. (Refer to 8121) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 144 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, CS, 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. Patient A20'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 titrate dosage as needed." 3. Patient B2's MTP dated 3/12/14 identified the problem, "Substance Abuse/Dependence." No FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 37 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMS NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION 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 interventions were identified to be provided by the psychiatrist. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE 8144 4. Patient B28's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality." The only intervention to be provided by the psychiatrist was "Order medication and titrate dosage as needed." 5. Patient 838'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/PanicAttacks." No interventions were identified to be provided by the psychiatrist. 7. Patient C6's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality." No interventions were identified to be provided by the psychiatrist. 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." 8. Interview During an interview with the Medical Director on 3/19/14 at 12:30 p.m., he acknowledged that the treatment plans did not list individualized treatment interventions, including treatment focus, based on the patients' needs. He acknowledged that there were no physician interventions present on the treatment plans. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 38 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OM8 NO 0938-0391 c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. B U I L D I N G - - - - - - - - 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 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 144 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, C6, and C19). This practice results in the inability to monitor discipline accountability for specific modalities. (Refer to B123) 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 transitional community services and community integration. (Refer to 8125 I) VII. 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. (Refer to B125 11) VII I. 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 8125111). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 39 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OM8 NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8 144 Continued From page 39 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 144 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. {Refer to 8133) 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 {D3 and DS}. 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) 8 148 482.62{d}{1} NURSING SERVICES 8 148 The director must demonstrate competence to participate in interdisciplinary formulation 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 C6} FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 40 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 148 Continued From page 40 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. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 148 II. Ensure that the nursing staff was identified by discipline for 6 of 8 sample patients. (A20, 82, 828, CS, C6, and C19). This practice results in the inability to monitor discipline 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 B2'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." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 41 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1} PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - 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 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION OATE B 148 4. Patient B28's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality." The nursing interventions included "Administer routine medications at dosage and schedule ordered and prn (as needed) medication for depression." 5. Patient B38's MTP dated 3/7/14 identified the problem, "Depressed Mood with Suicidality." The nursing interventions were "Administer routine medications at dosage and schedule ordered and prn medication for depression" and "Special Precautions to ensure pt safety." 6. Patient CS'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 prn medications for anxiety." 7. Patient C6's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality." The nursing interventions were "Special Precautions: Level of Observation Q 15 min checks" and "Administer routine medication at dosage and schedule ordered and prn 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 42 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 148 Continued From page 42 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 148 1. Patients A20 (MTP 3/11 /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 CS (MTP 3/4/14) had interventions with 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. 8. 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 B 152 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 43 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN QF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED 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 Director of Social Services failed to: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 152 I. Provide social work assessments that included an evaluation of the current baseline social functioning for 5 of 8 sample patients {A24, 82, CS, 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) II. 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, CS, 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. 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 44 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 NAME OF PROVIDER OR SUPPLIER 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 152 Continued From page 44 problem, "Substance Abuse/Dependence." The only intervention by social work staff was "Process Group Therapy {to) learn effective communication." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 152 4. Patient B28's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality." No social work interventions were identified to be provided by the social work staff. 5. Patient B38'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 CS's MTP dated 3/4/14 identified the problem, "Anxiety/Panic Attacks." "Psycho-educational groups related to s/s {signs and symptoms) anxiety." No interventions were identified to be provided by the social work staff. 7. Patient C6's MTP dated 3/10/14 identified the problem, "Depressed Mood with Suicidality." No social work interventions were identified to be provided by the social work staff. 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. B 154 482.62(1)(1) SOCIAL SERVICES FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 B 154 Facility ID: HL104016 If continuation sheet Page 45 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 154 Continued From page 45 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 154 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 staff member must have this qualification. This STANDARD is not met as evidenced by: Based on interview, the facility failed to provide either a director of social work who possessed a master's degree in social work (MSW) or assign an MSW staff to fulfill the duties, functions and responsibilities of the director of social work related to quality review of social work duties. 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 Biopsychosocial 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). B. Staff Interviews 1. During an interview with SW1, a clinical social worker intern (MSW), on 3/19/14 at 9:00 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 46 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING _ _ _ _ _ _ _ _ __ 104016 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 154 Continued From page 46 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. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 154 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. 3. During a phone interview on 3/19/14 at 9:1 O a.m. with SW2, a contracted LCSW who was assigned to perform quality assurance activities for the social services department, she stated that she did not review the quality of the 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. C. Document review A review of the document "Employee Listing of All Therapists for River Point Behavioral as of March 18, 2014" presented by the facility of all staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WSXR11 Facility ID: HL104016 If continuation sheet Page 47 of 48 PRINTED: 10/05/2015 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO. 0938-0391 A. B U I L D I N G - - - - - - - - - 03/19/2014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 6300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH JACKSONVILLE, FL 32216 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 154 Continued From page 47 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 c B. WING _ _ _ _ _ _ _ _ __ 104016 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION Event ID:WSXR11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE B 154 Facility ID: HL104016 If continuation sheet Page 48 of 48 Jrth.. ~;; RIVER POINT BEHAVIORAL HEALTH June 27, 2014 Ms. Jacqueline Whitlock Department of Health and Human Services Centers for Medicare and Medicaid Services 61 Forsyth St., Suite 4T20 Atlanta, Georgia 30303-8909 Attn: Ms. Jacqueline Whitlock and Mr. Donald Howard Re: Medicare CCN 10-4016 Dear Ms. Whitlock and Mr. Howard: This letter responds to Sandra Pace's letter dated June 18, 2014 and the accompanying deficiency statement for the survey at River Point Behavioral Health on June 2-4, 2014. Enclosed is the CMS form 2567 containing our response. We trust that you will find that the actions taken are acceptable and that you will authorize the surveyors' revisit at their earliest convenience. We take compliance with the Medicare Conditions of Participation seiiously, and we look forward to showing the surveyors the improvements we have made and that the hospital is in compliance with the rules. Please let our Interim CEO, Jennifer Wiggins, or me know if you have questions or need further information. Thank you for your help with this process. Sincerely, Roz Hudson Divisional Vice President Via Electro11ic Mail (!ackie.wlrltlock@cms.hhs.gov and Do11ald.l,oward@cms.l1hs.gov) Enclosure MAKING A DIFFERENCE IN MIND, BODY, SPIRIT. 6300 Beach Boulevard, Jacksonville, Florida 32216 Admissions: 800.749.3967 Phone: 904.724.9202 www.riverpointbehavioral.com 04/0712014 P.0021014 f~7243797 15:27 Nurstlg ffATIMl!NT OF D!PICIENCll!S AND PLAN OF CORREO'J'10N a WING 104018 NAME Of PROVIDER OR 8UPPLIEFt 8TRE5TADDRESS. OnY, STATE, ZIP aoo 111!.ACH !ILVD RIVER POINT BEHAVIORAL HEALTH JACKSONVILLE, FIL 32218 SUMMARY STATE!MENT OF DEFICIENCIES (EACM DEl'ICll!NOV MUST 81! Pl'lECeDED BY FUU. RE!i!JI.ATORV OR LSC IDENTIFYING INFORMATION) (X4)1D PREFIX TAG PROVIDl!R'S Pl.AN OF CORREO'I'ION I[) (!!A.CH COJltMIOTIVl!ACTION SHOUL.C Ii! OR08S.RS~R6NOED iO THE APPROPRIATE PREFIX TAG DEFIC~NCV) s~miaaion of this pl.ui. of A 000 correction is not an adm:I.Hion by the hospital that the ditations are correct o:r: that the hospital violated the rules. A 000 INITIAL COMMENTS An unannounced substantial allegation complaint survey, CCR#20140009541 was conducted at River Point Behavioral Health, on March 17~19, 2014. River Point Behavioral Health Is not In compllanoe with the Fsderal Regulations at 42CFR Part 482, Requirements for Acute Care Hospitals. A 144 482.13(0){2) PATIENT RIGHTS: CARE IN SAFE SETTING Ol/215/14 The cir11otor ,;,t Plant Opa'l:'at::l.on11, at the direction of th• CEO removed I •11 ~tra mattreaaes whioh ha4 ~ean used for overflow patient• from A 144 the facility, The Director of Vlant Operations added additional beds to 6 currant rooms to be used solely for ovarflo The patient has the right to reoeiv1 care in a safe setting. f due to Jaokaonville Sheriff Office JSO)or walk•ina that cannot be transferred to other facilitiee, ! I, i i I! Ii !! i Thi$ STANDARD le not met as evidenced by: Based on observations, Interviews and record reviewe, the facility failed to provide care In an emotlonally safe environment to promote respect, dignity and comfort on 2 (Emergency Stabilization and North) of 3 units. The Findings Include: . j ~ Vol ' 0<91 OOMPl.ellON DATE n V• 1. Our.Ing the lnltlal observation of the faomty on ··3117'2014 at 10:00· AM, an interview with the Oirector of Nursing {DON) revealed the faollity "'JJ consisted of 3 separate units. The North Wing , i has sa beds an.d houses male and female patients for chemical dependency and psych. The ~ emergency Stablllzatlon Unit (E:SU) has 26 beds ~ housing both male and female patients. The Older Adult Unit (OAU) has 26 bsds that houees malt and famal1 adult& over 55 years or age. The DON stated the feOlllty used cots for overflow patients, but the staff tries to arrange discharges throughout the day, so they can empty beds and not have to un cots. S. e ~ireotor of Pllillt Operations i,.cx,mpleting the re~ovation of • room on the 100 ha.llway(Olde~ dult Unit) that ( Wi18 4,/19/14 1mder ~ oonstruotion a~ the time of th• ~ survey that brings the fad:i.lity up to ita licen~ed bed oapaoity of ~:3. 0 The nirector of Evaluation• & Referral has reviaed the Patient Overflow policy to clarify that overflow pacienc; may only be aoeepted when the pati•nt has been d:opped off PY ~iO under the llker Act law11 or i1 a walk-in 04/04/14 with •n •mergent pi,yehiatric dgndition (meeting !MfALA definition)and the patient cannot b ransferred to another fa~ility due g laok cf beds. The pglidy wa1 11pprovad by Meaical Executive -~ TITLE (XI) DAT& 'f i 1'1 Any clefiel91lcy statement ending with aeterl&k (") dei,ote1 a del'lclenc which th• inatitutiQn m11r be elG'JUnd fl'Qm QQrrectlng providing It la cle rmlned that other aafeguarda pl'Ol/ide aufficient protection to the patients, (See Instructions.) Except for m1ralng home11 the flndlnga atated abovt are diecloHble 90 days following the date of eurvey whether or not a plan of correction la provided. For nursing home,, the above findings and plans of oorremlon ire diacloaable 14 day, foffowlng the date these document. IN made available to th• faolllty. If cletlc!encleS are cited, an approvaa pian of cormcuon ia requ11111 to conl:lnuld program p1rtlolp1tion. FO"M CMS..aoe7(02-H) Previous Vll'llol'II Obsolete !!\'ant 10: eV11Ae11 FacJIJ\\111); HL10401 e If continuation sheet Psge 1 of 13 04'07/2014 PRINTED; 03/28/2014 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR Ml=njt'!Ane & MEDICAID SE~v;.::-~ Sta.TEM!iNT OF D!FICJl!NCfl!S AND PLAN OF CORRECTION FORM APP~OVEO ~ AR (X1) PROVIDERISUPPL!Ef'/CLIA IDl:NTIFICATION NUMBliR: NO. 0Q~R..MQ1 ()(3) DATE SURVEY (X2.I MULTIPLE OONSTRUOY'ION A. BUILDINC:1 _ _ _ _ _ __ OOMPIETEC B. WfNl3 03/19/2014 104016 c 8~!!T AOOR!Sl!I, CIT\', STAT!; ZIP COile NAM! Oft PROVIDER OR SUPPLl&llt 8300 BEACH BLVD RIV!R POINT BEHAVIORAL HEALTH ~)ID PRIFI)( TAG P.003/014 0:~047243797 15:27 ttJrsi1g JACKSONVILLE, FL t221t SUMMARY STATEMENT OF 01:ffCIENCll!S (EA.CH Dl!FIOIENCV MUST Bl! P~l!CEDED BY l'ULL REGULATORY OR LS0 IDENTIFYING INFORMATION) ID flRl!FIX PROVIDIR'S PLAN OF CORRECTION (~Ol1 CO!ffif;CTIVEACTION VHOUI.C ISi C~SS•"EFIRINC!D TO THIAPPROPRIATE DEFJOIENCV) TAO (XS) COMPl.ll!ON IIA'l'i Comittae and Governing l!lody. A144 Continued From page 1 The unit obseivatlOns on 3/17/2014 at 10:00 AM revealed tha North Wing's census wae 42. There are cloth mattresses with vinyl coverings observed on the noor in a patient bed rooms. The mattresses are observed without sheets and pillows. A144 - The Director of lvaluation & :Ref&l'l'a1 baa p%ov:l.ded training on tho Patient Overflow policy &nd bed management requ.iremant to the l&R staff and all nursing •upsrvilors . The Staff Bducation Coordinator and Human Raaources Director have added the Patient Overflow policy to the orientation plu for dl An interview with the DON at 10:00 AM confirmed the North Wing Unit ia over capacity, despite already having 3 diecm1rges this morning. An to ensura that new amployaaa will reaeiva trtlninw in the future, otner. An lntervlflWWlth the DON at 10:16 AM 0,11111, The CNO/dasign•HII ha• provided training tc all n\lrsing •taff on expectation• related to the provi•ion of appropri•t• dining and sleeping 1paae1 for all revealed the mattrelHI on the floor (previously called cots) are for the overflow patients. An observation of the OAU on 3117/14 at 10:35 AM nwealed the census was 21: There are 28 patient•. beds on the unit One patient room ls observed . with 3 bedS and 1 mattr..a on the floor; there were no sheets or plllows observed on the mattress on the floor. An observation or a second activity room located Within the ESU on the opposite side or the nursing 04/18/14 nurBllJ:liJ sups:rvisors and E< staff observation of the ESU revealed the census wu 31 with 7 pending discharges. There are 7 mattreeses observed in a cfOHt touching each 2. An obaervation. of lunch In tbe ESU on 3/18/14 at 12:10 PM revealed the room was not large enough to aooommodate the 23 pati~nts who were attempting to eat lunch. The room Is observed with 4 round tables. Two patients are observed placing their food trays on the floor to add aaft and pepper. These 2 patients then plaoed the lunoh trays Jn their laps to eat. There wert 6 patients observed eating lunch while hOlding their food pistes In their laps, With their drinks on the floor. Two patients were observed standing at a counter eating. 04/11/14 Th• Oirector of Plant Oparatione 04/15/14 ha11 ova:r:meen th& development of increase~ dining apace. On the ESU unit, Che pbumaey, wbii:ih was located on tu ESU unit, has been relocated and that room has been converted into an additionai dining area/day room to ~aura that all patienta can be aaacmmotiated in the two rooma. On OAU unit, t:1'9 extra day room that was in use as storage at the time of the survey, has been cleaned out and converted to provide additional dining/ day room apaaa , , ·1 I Eventl0:6WA811 FIICIII~ fl); HL1040111 If c::ontlnuatlon sheet Page 2 01' 13 04107/2014 PRINTED: 03/28/2014 FORM APPROVED DEPARTMENT OF HEALTH ANO HUMAN SERVICES 0 CENTI;RS FOR MEDICARE & ·--;.;,- \10 SERVl~FS STATSMENT OF DEFICll!NCl!!S AND PLAN OF CORR!OTION P.0041014 f~47243797 15:27 Nll'Sil9 (X1) PROVIDER/SUPPLIER/Cl.IA IDENTIFICATION NUM8i;:R; A, n--- ---1 ,JI~ Mn (X3) CATI SURVEY COMPL!iED (X2) MULTIPLE CONSTRUCTION IUILDINC _ _ _ _ _ __ c 1040.16 l!.WINU NAME OF PROVIDER OR SUPPLIER sr~eer ADDRESS, CITY, STAT!, ZIP COD! RIVER POJN'r l!l!HA.VIORAL HEALTH HOO a&ACH BLVD JACKSONVILLE, FL 32216 (X4) ID PRSFIX TAO SUMMARY STATEMENT OF DliFICIENCIES (IACH CIIFIOlliNOYP4U8T Bl;; PRECEOED BY FULL REGUL.ATORY OR LSC IDENTIFYING INFORMAilQIIO 0311912014 PROVIOE!t'S Pl.AN OF CORR!CTION (S\OH COMl!CTM! N:TION SHOIJl0 19! ID PREFIX TAG ()(5) COMPI.ITION WITl!I CROSS:-REFERENCEDTOTHEAPPROPRIATE •-· - - __ ... ,.,. Dli~~ENC~ ., __ •• , In A,,.. /S .4 Sarvicas have modifit;9\IIIA911 l'IGIR\Y IC: HL104D1t If oontlnuatlon eheat Page 5 or 15 0410712014 PRINTED: 0312812014 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & Mcn11"11.in ~=RVJCES STAT!M!NT Off DIPICIINCIES AND Pl.AN OF CORREO'J'ION {X1) PROVIDER1$UPPl,f!;R/CLIA ll>ENTIPICATION NUMBER: 104018 FORM APPROVED OMB NO. og~MSCM it,, BUJl.DINf1, _ _ _ _ _ __ CONIPL!'h:D B.WING 03/18/2014 c STJQl!T ADDA!H, CITY, 8TATI!, ZIP CODE 8300 BEACH BLVD RIVER POINT BEHAVIORAL HEALTH (X4) ID (X8) DATE SURVEY (X2) MIJLTIPLli CON&TRUOTIOM NAME OF PROVIDl!R OR SUPPLIER PIU:FIX TAG P.007/014 (F~47243797 15:28 Nursilg JACK80NVILLE1 FL 32216 SUMMARY SI'ATeMENT OF DiiiFICIINCl!S (EACH DSF!ClliNCY MUST BE PFU!Cl!Ol!O SY FULL Rl:GULATORY OR l.aC IDl;NTIFYlNG INl'OR~TION) IO PREFIX TAG PROVICER'S PLAN Off CORRECTION (!ACH CORRl!CTIVI: ACTION SHOULD BE CROSS.REFiRINCICI TO THEAPPROPRIAT! OEFICIENCV) 'l'he CHO modified th• Restraint/ A 454 lilec:lution order foi:m to indlude A 454 continued From page 5 The Findings lnolude: ~,/07/14 a spacifia line for the physician to authenticate hia/ner order. 1). A medloal record review for Patient #J13 revealed that she was involuntarily admitted Into ~he facUlty on 1/2312014. On 212/2014, Patient #J13 was cbaerved banging and kicking the door to the nurses' station while thmtening staff. An emergency lntatventlon telephone order was received at 12:07 AM for physical reetreiint, seclu81on, and mecffcation restraint. The maximum time ordered tor this Intervention is 4 houra. The orltll'lon for release IS that Patient #J14 mUtt oalm dowrt The physical restraint time ia documented at one minute trom 12:07 AM to 12:06 AM. Seclusion wa1 Initiated at 12:08 IW!. Patlent#J13 Wai chemically restrained using Prolixin s1:1g IM for psychosis and Benadryl 60mg IM foramoety. Pafient#J131s seclusion ended at 1:05 AM. An observation of tha medical record revealed that the restralnt/seclumon telephone orders have not been authenticated. 2). A medioal record review for Patient #J14 reveals hewn lrwolul'ltarlly admitted into the facllty on 1/17/14. On 1120/2014 at 5~4 AM, Patient #J14 was observed ouraing, yelling, and threatening other patients and staff. Emergency iOb!JMlntfon orders for ~alnt, oh•mical restraint and seclusion was Initiated \/ia a telephone order for a maximum time of 4 hours. Tne ordered use of chemical reatralnt Includes Haldol 5mg lntramusoularty (IM) for payohosfa and At1van1 mg . IM for agitation. The cllnlcal JustlfloatlOn is that Patient #J14 was a danger to others. Patient #J14 was in eeclueJon from 5:04 AM tc 6:21 AM. An observation cf the medical record reveals that the reetra1nt/eeo1Uslon telephone ordc,rs ha\/8 not been authenticated. !vant 10.0WAl11 IAll psyehiat~i•t• received OJ/27/14 ~•·training on the need to authenticate thair restraint/ seeluaiCll'I orders wit:.bin the requi~e, time fnm•. The CNO provided t:taillizig to the P.H staff on ta 04/11/14 noecS to flag llny' reetraint/sealue!on order for siS1natur• by the physigian. The ClNO/deeiwn••• are inonitorins lOOt of ~••t~aint/sealuaian doculll6Ilt11tion within 24 houra of the int,rv-=.tion to ensute that the oz:der i, authentioatea within the rl!lquired time frame. lf the order ha1 not been authenticated by that time period, the ONO/ daaignee will cientaQt th• i.,hysic:l.an auid Medical Direotor. Ag;resjata data wiii ~. reported monthly to Quality CC'l.1Dcil and the Mediaal Executive CollDllittae, and quarterly to the ilovem:l.ng Elody. Monitoring Will be dc!ne fo~ at least 90 days or until satisfactory complianoe ie aahieved. Any phy1101.n not in OQh\Plian9e will be aounl!Blsd by the Medioal ' Director and dooum.1ntation plaoed in their OPP~ ~ile fo~ dOn•ideratior at the time of re-appointment. FaCIIIIV ID; I-IL1114018 f4/1s/1, on-goin! tr continuetio11 sheet Page OOf 18 04/07/2014 f A.U0472437S7 15:29 Nursilg PRINTED: 03/2812014 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTER~ FOR MEDICARE & M-"':::"" -.in SERVICES STAT!!MENT Of:I Dl;FIC:UiNClSS AND PLAN OF CORRiCTION FORMAPPROVEO . n (X1) 111\0IJID!A/SUF'PLIER/CLIA A. !UILCllNB _ _ _ _ _ __ COMPL!TEP. B.WING 03/19/2014 c NAME OF PROVIDl:!ft 01\ SI.IPPLIER STF!i:;il' At1DRIS8, CITY, STATE, ZIP CODE ftlV!lt POJNT BEHAVIORAL HEALTH 6300 BEACH BLVD JACKSONVILLE, FL 32216 TM 11s NO. na~a-0391 (X:11) DAT! SURVl"f ()(%) MULTIJIILI! CONITFUJCTION IP!NTIFIOATION NUMSER; 104016 (X4) IO P'l'ti=!'IX P.0081014 A 454 Continued From page 6 3). An interview with the Director of Nursing (DON) on 3/18/14 at 3:48 PM oonflrmed after revlewtng the medical record ·that the Physician never signed the telephone order !'or the Physical and Chemical restraint. or Seclusion. It Is a facility's expectation that physicians sign telephone orders for an restraints and seclusion. When asked, the DON revealed that she would try to get the phytilolans on the telephone to talk to this Surveyor regarding eigning telephone orders. PROVIDER'S PLAN OF CORRECTION (EACH COl'tl'tECTIVEACTION lllHOULP BE CR0$S,REPEIU!NOlill) TO THIAi.ftOP'ftlATE DEFICIENCY) ID 8UMMAftY STATl:MeNT OF DEFICIENOIES (EAOH DeFICIENOY MUST Ii&: PRICIDl!iD ev !'I.ILL REGULATORY OR LSC IOENiiPYINQ INFORMATION) PRl!FIX TAG A 464 I 4). An Interview with the Director of Clinical Servioes on 3/19/2014 at 12:20 PM wtille reviewing the medical records for Patient! #J13 and #J14 reveals that physicians are supposed to sign telephone orders to include reatraintlseoluslon orders within 48 houra of order Initiation. The Director of Cllnioal Services confirmed that the reatraint/aecluslcn orders have not been signed for either patient She stated thie has been an ongoing faclllfy Issue. Phyalolans are aware that they are supposed to sign the telephone orcfera ln 48 hours, but they Just do not do.It. . . 5). An lntentiewwith the DON on 3/1;12014 at 1:30 PM reveals that none of the physicians who are identifiecl as not elgnlng the restralnt/11olualan orders a~ in the faclllfy at the preeent time. The DON was asked by this Surveyor If It wae possible to talk to one of th• physicians by phone since they were not In the flc!llty. The DON stated that both physicians have a daytime practice wlth patients, so she was unsure If they would be available at this time. The DON was given thla suiwyofs cell phone number and asked to have the physician call baok. At 2:15 PM, the DON attempted to Event ID: eWA911 I Faol!i" ID: HL10411111 If contin,uation sheet Page 7 of 13 04/07/2014 PRINTED: 03/28/2014 FORM APPROVEC DEPARTMSNT OF HEALTH ANO HUMAN SERVICES . CcNTi;;n.S FOR I\AEDICA~E & MEDICAID SERVICES STATIMliNT OF CliFIC&IOIIES AND Pl.AN OF CORRECTION P.009/014 · J~47243797 15:29 Nurstig ()(1) PRQVJDEIWUPPLIER/CLIA ICliiNTIFICATION NUMBER: O AB NO. o--- ~~~1 • ()(SJ DAi.1 surwav ()(2) MULilP..LE CONeTRUOTION A. l!IUILDINCI _ _ _ _ _~~ COMPL&TEO c 104016 B.IMNG STREET ADOFIESS, onv. STATE, ZIP CODE aoo BEACH BLVD NAME OF PROVIDER OR SUPPLl!R RIVER POINT lll!HAVIORAI. HEAi.TH (X4)10 PRl:!PlX TAG 03/1 Al2ft14 JACKSONVILLE. FL 32218 SUMMARY STATEMENT OI' Dl!l"ICIINCll'!S (!AOH DEFJOleNC'l" IIIU~ se PREOe!Ol!C i,y FULL Rl!GULATimY OR LSC IDENTll'YIN~ INl'ORMAi'ION) A4f34 Continued From page 7 follow-up to see 11 a physician had made contact with this Surveyor. The DON stated that she would call flgain and leave anoth&r message to the physic/an to call this Surveyor. There was no call received by th!$ Suiveyor from a physician I! regarding th18 matter. PIU)VIDl!R'S PLAN OF COAAecTION (Ell.CH CORRECTIWAOTION SHOULD lie! CROSS.Al!l'l!PIENCl!iD TO l'Hl:APPROPRIA.TE! ID PR~ iACJ 0(6) COMl'I.ETION OAT! DEFICIENCY) A454 6). A review of the pofloy and procedures for telephone ordare with an effeotlve date of 1112004 and a la&t revised date of e/2009 reveals that physician telephone ordel'i must·be authenticated within 48 hours. lfthe practitioner is off duty, then another praotltloner who ia responsible for the patient's care can authenticate the verbal order of tha ordering practitioner. A 820· 482.43(c)(3), (6) IMPLEMENTATION OF A DISCHARGE PLAN (3) The hospital must arrange for the Initial Implementation of the pati1nfadlscharge plan. (6) As needed, the patient and family membere or Interested persons must be counseled to prepare them for post-hospital care. 04/05/14 A 820 :rb.e C1~tct:o:r: of SOCl:1.ill SliltnC:lillil reviewed and revised. the Policy "Diacharg• Planni~g" to en•w;-e ~ t the disaha.rge planning proae•• ~gtation8 are dorrectly identified· indl~4ini ~edtat1on8 •o~ the therapi•tl•ooial worker to '1leet with the patiertt early in treatment, throughout treatment, ·and within 3t houri diaaharge to develop, mod1fY, and finalitie the Pischarga/ccntitluing ca~e Plan. ~leo ·olarifi•d in the policy i i the ~actation that th• fi~-l ~.-vi•w of t:h9 di•oharge/continuing care plan ~ith tu patient occurs on the day pf discharge and the patient'• ~•presentative 1 s (if appropriate) signature i• ob~ain~ at that t~me, in4ioacing their ~greement with and understanding of the plan, of This STAN DARO is not met as evidenced by: Based on·medreaf record reviews, patient and staff Interviews, the tacilfty failed to ensure that patients and/or family were involved in the discharge planning process for 6 of 11 sampled petients (#1,#2,#4,#5,#6,#11}. The Findings Include: Review of the medical ·record for Patient #1 Event 10: 8WA911 Fa1;llly ID: HL t04010 tf O(lntinu1t1on eheet P-ae aot 1a 0410712014 STATEMENT OF l;leflOli;NCIES AND PLAN OF CORRECTION (X1) PROVIDEA/SUPPl..l~CLIA JOeN11FIOATION NUMBER: (>Ca) bAiE SURV£V OC2) MULTIPLE OONSTRUCTION A, ISUILDINC _ _ _ _ _ __ 104018 OOMPLl!TED c B, WING NAME OF PROVID!R OR SUPPUER 03/19/2014 SiREST AIXIRl!SI, CITY, STAT!, ZJP CODE HOD Bli.ACH 191.VD RIVER POINT BEHAVIORAL Hl!ALTH ()(4) ID PREFIX TAG P.0101014 fAX;i047243797 15:29 Nursilg JACl(9QN\llLLI!!, FL 32218 SUMMAl'lY STArEME;NT OF DEPICll!!NCll!3 ID (EACH OEFIClliNCY MUST lilE PREOEDal 8Y FULL MGULATORY OR I.SC loe!TIFYINC3 INFORMATION) PREFIX TAG PROVIDE;R'S PLAN OF COltRECTION (IACH COMl!OilVEA(n'ION SHOULD U COMfoleTION eitOSS~EFERE:NCec TO THEAPPROPRfATE DA'!! DEFICIENCY) he Pir..::tor of soeial services A 820 evised the rnedicial record forms ,,ooiated with the disoh&rge l&nning ~~=e•• to more clearly ocument the initial and ongo:l.n9 ,charge planning activities 1th the patient, family, and A a20 Continued From page 8 ·revealed she was admitted to the facility on 3/9/14. Her discharge plan was. to return to her previous rMng arrangement, and tne Patient liignrature was dated 3/13/14. On 3/17114, the patlentwas atill obaarved to be in the facility. Q(li) I 04/01/14 I thera as need•d.· Interview with Patlent#1 on 3/17114 at 10:15 AM revealed she waa admitted last Sunday and ahe is leaving with her flane6 and wDI be ttQylng at the I Emeraon Inn Motel, beoause she Is homeless. She stated ,he hu already signed her discharge fonne a couple of days ago and they will give her prescrlptiona for her medlc,atlon when ahe ia diechargod. I JnteMew with Patient #2 on 3/17/14 at 10:26 AM raveled he was admitted last Tuesday. Hi, stated he waa being discharged today to his mottlet's oare. Review of the medlcal record for Patient #!.2. revNfad he was admitted on 3/11114 and his final dlsOharge papers were signed on 3/14/14. His final discharge forms.lnclUded statements that his current medication llstwas given and explained. A copy of the Discharge Safety Plan was given and reviewed. A copy of all diaoharge lnetructfon was given and reviewed. Patient's personal belongings from bedroom, belongings room 1::1nd eafe have been returned. Educated and provided hand-out on •Faots about Suicide and Depression" to patient and significant . other/guardian. including "Black Box Warning for SSRI." ha Direator of Sooial Services d nirector of utilization Re'V'iew ve hired a Discharge Planner to assist 'the ch.erapist/sooial work•~• in seheduling appo1ntmenta •• eeded to ensure a thorough ontinu:l.ng cue plan h•s be$n velope~ prior to diaciharge. 04/ll/14 e Director of Social S•:i::vioet 04/11/14 s p~ov1ded training tQ all thm:-apy/1oaial work •taff, RNs, •taff, an~· the Di•cb.rge Plann•r the revised prooaases outlined :Ln the ti.Discharge Planning• policy. he Staff Bducation Coordinator 4/18/14 and Kuman :Ra•ouroe Direoeor ~ave :t!l.aorporated disQhllrge· plann1ug into the o~ientatian prOQ"ram for RN, therapieta/soaial worker1, ,lll'1d 1eatf .eo eneuri th&t new •mployee1 receive t~aining on th• revised :process, Review of the medical record for Patfent #4 revealed 1he was admitted to the facility on Evant ID:flWA911 Fadllly ID: HL104018 · If aonttnu•Uon sheet.Page 9 of 13 0410712014 P.011/014 15:29 Nlff'Silg PRINTED: 03128/201-4 · FORMAPPROVEO 0 STA'l'l:MEIIIT OF DEFICliNClES ANO PLAN OF CORRECTION (Xi) PROVIDSfl/SUP.l'LIERIOUA IDENTIFICATION NUMBER: 0319/20 STREETADCRESS, CITY, STATE, ZlP CODI!! NAM! OF PROVIDER OR SUPPl.leR 9300 e!ACH SLVD RIVER POINT BEHAVIORAL HEALTH JACKSONVILLE, FL 32216 SIJMMMtY S'l'Ait!MENT 01" DEFICIENCIES (EACH t'l!FICl!NCY MUST 19! PR!C!O!.D !SY FULL REGUI.ATOIW Ort I.SO rDENnFYllllG lll{F°"MATlON) TAO 1 c a. WINli 104018 = 8 (X3) CATE: IURVIY COMPLE'l'l=O (l(2) MU1.Tll'LI! CONSTRUCTION . A. 8UILOJNG _ _ _ _ _ __ A820 Continued From page 9 3/4/14. Herflnal discharge papers were signed on 3/7/14 to return to previous living arrangement. Patient #4 wes obsel'Vid on S/17/14 to stlll be In the faofflty. An lnteivlew was conduoted with the Director of Quality on 3/17114 at 2:30 PM. She WM asked to revtew the medical reoorda of Patient #2 and Patient #4, to explain why the discharge papers were filled out In advance of the patients' discharge and she stated she did not know. They will have to be signed again on discharge, so I don't know why they were ali,ady signed. I Interview with the Charge Nurse on 3/18/14 at 9:30 AM revaalad her part of dlsoharge planrilng starts the day of discharge. The therapist doee her portion a little before the disoharge. The patient Is supposed to sign the forms When they 91'6 dlscharga1. Reoel'ltly, we have been having the patklnt sign all their fOrms at their first team meeting, but I don't know the reason. I think It Is good for patients to sign them when they are competent aFld that Isn't always at admission. IC P"°V'ICIER'S Pl.AN OF OOMECTION ("5) OROS$-REFeRiNC5D TQ THiAPPAOl'llllATE COMPLITtON DATE! (IACH COARSCTIVl!!ACTIQN fJl'IOVLO BE PREFIX TAG DEFICIENCY) A820 he Director of Social se~v1cee 04/15/14 d UR. are 11101'.itodng lOOt of on-goi i•charge Conti~uin; ca~• ilan• to sure that th• patieri.tra signature • obtained on th• day of di•oharge o verify understanding of and wra91118nt with the 01schar;e ontinuing Oare Plan, the plan a appropriate for the patient, d that tlul pl1n aQC\\~ately apra1ents the patient'~ discharge l~i11S, l'1Hclll, regated data :Ls preHnted. thly to t:he Quality Counoil 04/18/14 qn-ggin Me~ioal ~eout:!.ve Committee quartarly to tba Goveni.ing iody. itorin; will btl dona ~or at least o day• or until ••U.s:l:t.otory omplianca ie aohieved. ¥ amployeee not 1~ oo~lianoe ill ba add.r••••d t.h3:ou;h reducat.ion and/or disciplinuy aotion s a.ppropriata. nd Ii Observation of the treatment team meeting for Patfent#4 was conducted on 3/18/14 at 10:00 AM. The Medfcal Director left before the meeting began; the Charge Nurse and Therapist were present along With Patient #4. The discussion was about the Auleted Uving Facillty not wanting Patient #4 to return to the faeiltty. Interview with the Therapist on 3118/14 st 10:65 AM revealed they are trying to prepare ?atlent #4 for discharge. She stated we meet with patients Event 10: OWAi11 FIICJIIIV ID! HL104018 If contlnuatlon llhfft Page 10 of 13 0410712014 PRINTED: 03/28/201"4 FORMAPPROVEO Cl tAR ND. 09~R..Q3511 DEPARTMENT OF HEALTH AND HUMAN SERVICES 1.,c:,.., 1c:n.o FOR MJ:nlQA~i= & MEDICAID SERVl~i:-~ STAT!MENT OP l&'IOle.NOll:S .AND PLAN OF CORRECTION ()(1) PROVID&RISUPPLIE~OLIA IDENTIFICATION NUMBER: 10401& TAG. COMl'l..lm c B. WING 03/19/20f4 8TPl&&T ADDRESS, CITY, STA'ri;, ZIP CODE 8300 EIEACt.l BLVD RNl!lt POINT ll!HAVIOl'AL HeALTH (X4) ID (XS} OA'l'E SURVl!!V (X2) MUI.TIPLI CONSTRUCTION A. 8UILDIN<3 _ _ _ _ _ __ NAME OF PROVHl!R OR SUPPi.i~ PREFIX P.012/014 l,FAll~7243797 15:30 NurSilg JACK80NVILLE1 PL 32218 SUMMARY STATl!Ml!NT OF Dl!FICleNOIES (EACl-t 01;ff0111!NOY MUST IE PRECED!O BY FIJLL REOULATORV OR LSC IDENTIFYING INFORMATION) · Ae20 Conttnued From p11ga 1o Pl'IOVJDl!f8 PLAN 01' COM!CTION ID (l!MJH CORI\EOTIV! ACTION SHOULD l:IE OROSs.RIPl~INeEC TO TM!APPROPRIATI Ml!FIX iAO ()(&J COMPLETION DATE D!!FICIENOV) A 820 every 7 days to see if they are meeting goals. She revealed she is the discharge planner. We discuu an paperwork within 48 hours of .admission and patients are lnstruoted to sign their dlsdlarge papers 11t that time. If things change, then we put a line through them on the form. The patient doNn't re-sign the ohanQeij, Discharge planning starts at ldmlaaion. If things ohange, then we put a line through them, but no, the patient is not asked to re-sign. When asked how the facility documents, if the patient Is advised of the changes or imlQIVed in the declalon, she elated t guen we don't. I I ReVlaw of the medical record for Patient #6 revealed she was admitted to the facillty on 3/24/13 and her discharge papers were signed on admission. The patient waa discharged from the facUity on 4/5113. Review of the medical reoord for Patient #6 revealed she w.s admitted to the facility on . 419/13.and her.discharge paper.& wer.e signed on admission. The patient was discharged from the faclllfr on 4/16/13. Observation of the discharge process for Pallant #11 was conduQted on 3/16/14 at 11 :20 AM with the Therapist. Patlent#11's discharge planning papers were blank. The Theraplat stated $he wanted ta discuss her discharge plan. She asl