PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: OMS NO 0938-0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - R 144040 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)10 PREFIX TAG 11/30/2017 DES PLAINES, ll 60016 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 (XS) COMPlETION DATE {B 000} {B 000} INITIAL COMMENTS An unannounced follow up to a full survey after a complaint was conducted by Federal consultant surveyors from 11/28/17 to 11/30/17. The census at the time of the survey was 119. The sample of active patients was 10. Additional four (4) non-sample patients were selected for a focused review of alternative treatments. {B 122} TREATMENT PLAN CFR(s): 482.61 (c)(1 )(iii) {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 treatment plans that delineated active treatment interventions to address the specific treatment needs of 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10).1nstead, treatment plans included interventions that were routine, generic discipline functions or were patient goals. Despite each patient presenting with unique psychiatric problems, intervention statements were identical or similarly worded with no method of delivery identified (individual or group sessions). This deficiency results in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to interdisciplinary treatment. Findings include: A. Record Review The MTPs for the following patients were LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6)DATE 11/30/2017 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 to: B02C12 Facility 10: ll HOSP5915 If continuation sheet Page 1 of 23 PRINTED: 06/11/2018 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/CLIA IDENTIFICATION NUMBER. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - R 144040 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG 11/30/2017 DES PLAINES, IL 60016 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 122} Continued From page 1 (XSI COMPLETION DATE {B 122} reviewed (dates of plans in parentheses): A 1 (8/4/17), A2 (S/11/17), A3 (7/31/17), A4 (S/4/17), AS (8/11/17), A6 (7/31/17), A7 (S/1/17), AS (S/9/17, A9 (8/8/17), andA10 (8/9/17). This review revealed the following deficient intervention statements assigned to the psychiatrist (MD), registered nurse (RN), social worker (SW), and activity therapist (AT): 1. MD Interventions: The following identically worded deficient intervention statements were identified for patients despite their different presenting psychiatric symptoms and problem: a. Ten active sample patients (A1, A2, A3, A4, AS, A6, A7, A8, A9 and A10) -"Monitor and educate precautions, risks, benefits and side effects of medications during each visit or discuss possible medication options." Three active sample patients (A1, A2, and A3)"Assess for severity of impairment in daily functioning." Seven active sample patients (A4, AS, A6, A7, AS, A9, and A10}- "Assess/adjust medication efficacy during each visit based on patient's symptom recognition." These intervention statements were non-specific and did not provide a focus of treatment with descriptors of each patient's unique problem or symptoms. Interventions regarding assessing and monitoring were normal MD functions. The intervention regarding educating the patient failed to identify specific medications that would be taught and did not state whether teaching would be delivered in individual or group sessions with the patient. FORM CMS-2567(02·99) Previous Versions Obsolete . Event ID: B02Cf~ Facility ID: IL HOSP5915 If continuation sheet Page 2 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PlAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: OMS NO 0938-0391 (X2) MUlTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - R B. WING 144040 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG 11/30/2017 DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGUlATORY OR LSC IDENTIFYING INFORMATION} {B 122} Continued From page 2 PROVIDER'S PLAN OF CORRECTION { EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG {XS) COMPLETION DATE {B 122} 2. SW Interventions: The following identically worded deficient intervention statements were identified for patients despite their different presenting psychiatric symptoms and problems: a. Four active sample patients (A1, A2, A3, and A8)- "Teach coping skills to assist the patient in effectively managing intense emotion and tolerating distress." b. Three active sample patients (A3, A4, and A7) -"Staff will encourage pt. [patient] to take medication every day at scheduled times." c. Two active sample patients (A2 and A3}"Provide psychoeducation on symptoms recognition." d. Patient A9 and A 10 - "Assist the patient in identifying underlying thoughts and emotions related to being a danger to others through CBT model." These intervention statements were non-specific, did not provide a focus of treatment with unique descriptors of each patient's unique problem or symptoms. They also failed to include whether they would be delivered in individual or group sessions. 3. RN Interventions: The following identically worded deficient intervention statements were identified for problems associated with "Assaultive/Homicidal" and "Elopement. These intervention statements were identical despite each patient's unique presenting psychiatric symptoms and problem: FORM CMS-2567(02·99) Previous Versions Obsolete Event1D:B02C12 Facility ID: IL HOSP5915 If continuation sheet Page 3 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPUERICUA IDENTIFICATION NUMBER: 144040 OMB NO 0938-0391 {X2) MULTIPLE CONSTRUCTION R 11/30/2017 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED· A BUILDING-------- DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 3 a. Four active sample patients (A1, A2, A4, and A9)- "Assess cues and warning signals such as behavioral changes, escalating anger, hyperactivity." "Assess for the past violent acts so preventative actions can be taken." "Maintain a therapeutic environment with clear, specific rules and consequences." "Provide individual and/or group counseling." 'Teach patient to use coping mechanism appropriately to adapt more effectively with stress and anger." Frequency was listed as "Ongoing" or "As indicated." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {B 122} Interventions related to assessing cues, assessing past violent acts, and maintaining a therapeutic environment were all routine nursing duties and functions and did not reflect active treatment interventions provided in individual or group sessions to assist him/her to improve presenting psychiatric symptoms. The intervention related to teaching coping mechanism was a non-specific and broad statement and failed to include whether the teaching would occur in individual or group sessions. 4. AT Interventions: All of the active sample patients (A1, A2, A3, A4, A5, A6, A7, AS, A9, and A10) had the following identical or similar worded interventions despite each patient presenting with different psychiatric symptoms: "Engage the patient in therapeutic activities to find alternative forms of expression and increase self-fulfillment." Frequency was "7X/Week." This intervention statement failed to identify specific therapeutic activities for each patient based on his/her assessed needs and problems. Also, the statement did not include whether therapeutic activities would be delivered in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B02C12 Facility ID: IL HOSP5915 If continua ~on sheet Page 4 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERJSUPPLIERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ R 11/30/2017 B. WING 144040 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 4 individual or group sessions. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPR!ATE DEFICIENCY) ID PREFIX TAG (X5t COMPLETION DATE {B 122} 5. The following active sample patients also had the following deficient interventions listed for social workers. They were generic, non-specific, and not based on unique clinical assessment information. No delivery method identified. a. PatientA1- "Teach patient psychoeducation about the importance of the compliance with medication." b. Patient A4 - ''Therapist will assist pt. {patient] in identifying 2-3 triggers and/or stressors resulting in being a danger to others." c. Patient A5 - "Provide psychoeducation on positive reflection and using positive memories to cope with grief/loss of a loved one and negative feelings related to trauma." d. Patient A6 - "Social worker will work with patient to recognize safe ways to communicate concerns." "Assist patient in recognizing coping strategies available to utilize when feeling overwhelmed and experiencing racing thoughts." e. Patient A?- "Teach coping skills to assist the patient in affectively managing feelings of hopelessness." "Therapist will review ways to express emotions to parent and brothers feeling anxious." f. Patient A8 - ''Therapist will review ways to get in communication with staff in group home to access as a support system." g. Patient A9 - ''Teach coping skills to assist the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B02C12 Facil ty 10: lL HOSP5915 If continuation sheet Page 5 of 23 PRINTED: 06/11 /2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) IWLTIPLE CONSTRUCTION R 11/30/2017 B. WING 144040 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4) 1D PREFIX TAG (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 5 patient in affectively managing intense emotions and tolerating distress and grief." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {B 122} h. PatientA10- "Assist patient in finding positive, hopeful things in [his/her] life that contribute to healthy emotional well being." These intervention statements were non-specific, did not provide a focus of treatment with unique descriptors of each patient's unique problem or symptoms. They also failed to include whether they would be delivered in individual or group sessions. 6 . Patient A4's MTP also had the following deficient intervention statements listed for the RN: RN Interventions: For the problem of "Elopement," the interventions included were, "Monitor patient for inappropriate behaviors such as standing by the door ..." "Reinforce the treatment plan with patient and explain how attempts to elope may affect the length of stay." "Reinforce unit restrictions for the patient if necessary." 7 . PatientA8 and A10 had no interventions to address presenting psychiatric symptoms and problems. B. Interviews 1. In an interview on 8/16/17 at 12:20 p.m. with the Director of Clinical Services/Social Work and Director of Quality Improvement, intervention statements on MTPS were discussed . They did not dispute the findings that many intervention statements were normal job duties of clinical disciplines. FORM C'-AS-2567(02-99) Previous Versions Obsolete EventiD: B02C12 Facility ID: IL HOSP5915 If continuation sheet Page 6 of 23 PRINTED: 06/11 /2018 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLlERICLlA IDENTIFICATION NUMBER: FORM APPROVED OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION ( X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - R 144040 B. WING 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG 11/30/2017 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 6 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS,REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION OATE {B 122} 2. During an interview on 8/16/17 at 3:00 p.m., the Clinical Director acknowledged that MD interventions included normal MD duties. He agreed that MD interventions were "not specific to individual patients." 3. In an interview on 8/16/17 at 2:45 p.m., with the Director of Nursing, the preprinted form with the problems of "Assaultive/Homicidal, SAO [Sexual Acting Out], Elopement, and Arson" that was completed by registered nurses was discussed. He acknowledged that problem statements on the MTP did not have unique descriptors for each patient. Based on record review, policy review and interview, the facility failed to develop treatment plans that delineated active nursing treatment interventions to address specific treatment needs of 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10}. Instead, treatment plans included nursing interventions that were routine, generic discipline functions. In addition, for each patient with the same identified problem, the nursing interventions were the same. This deficiency results in treatment plans that failed to reflect a comprehensive, integrated and individualized approach to treatment. Findings include: A. Record Review 1. Patient A 1 (Master Treatment Plan dated 11/21/17) had the following nursing interventions for the problem, "Danger to Self, attempted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:B02C12 Facility ID: IL HOSP5915 If continuation sheet Page 7 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X 1} PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY COMPLETED - A. B U I L D I N G - - - - - - - - R 144040 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4}1D PREFIX TAG 11/30/2017 DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 7 jump off the bridge": PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (X5) COMPLETION DATE {B 122} a. "Place patient on Suicide Precaution to prevent self-harm/suicidal behavior per physician's order." b. "Observe for behavior indicative of suicidal ideation, and ask direct questions to determine suicidal intent, plans for suicide, and means to commit suicide." These were routine, generic discipline functions and were not individualized. 2. Patient A2 (Master Treatment Plan dated 11/20/17) had the following nursing interventions for the problem, "Danger to others, hearing voices telling [patient] to stab partner": a. "Place patient on assault, homicidal precaution to prevent harm to peers/staff from aggressive behavior per physician's order." b. "If patient exhibits aggressive or threatening behavior, redirect patient by verbal de-escalation hands-on techniques." c. "Question patient directly to determine whether patient has any impulses to assault others." These were routine, generic discipline functions and were not individualized. 3. Patient A3 (Master Treatment Plan dated 11/18/17) had the following nursing interventions for the problem, "Danger to Self, has a [history] of [suicidal ideation]": a. "Place patient on Suicide Precautions to prevent self-harm/suicidal behavior per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B02C12 Facility 10: IL HOSP5915 If continuation sheet Page 8 of 23 PRINTED: 06/11/2018 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: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION R 11/30/2017 B. WING 144040 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDIN G - - - - - - - - DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 8 physician's order." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {X5) COMPLETION DATE {B 122} b. "Observe for behavior indicative of suicidal ideation, and ask direct questions to determine suicidal intent, plans for suicide, and means to commit suicide." c. "Conduct room checks for sharps/contraband/excessive linen and explain to patient rationale." These were routine, generic discipline functions and were not individualized. 4. Patient A4 (Master Treatment Plan dated 11/21 /17) had the following nursing interventions for the problem , "Danger to Self: daily drinking of alcohol and feeling to kill self': a." Place patient on Suicide Precaution to prevent self-harm/suicidal behavior per physician's order." b. "Observe for behavior indicative of suicidal ideation, and ask direct questions to determine suicidal intent, plans for suicide, and means to commit suicide." c. "Conduct room checks for sharps/contraband/excessive linen and explain to patient rationale ." These were routine, generic discipline functions and were not individualized. 5. Patient AS (Master Treatment Plan dated 11/21 /17) had the following nursing interventions for the problem, "Danger to Others, threw garbage can out room window'': FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B02C12 Facility 10. fL HOSP5915 If continuation sheet Page 9 of 23 PRINTED: 06/11/2018 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) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCT lON R 11/30/2017 B. WING 144040 STREET ADDRESS, C ~TY. STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 9 PROVIDER'S PLAN OF CORRECn ON (EACH CORRECTIVE ACTION SHOULD BE CROSS·REFERENCED TO THE APPROPRIATE DEFICIENCY} ID PREFIX TAG (X5) COMPLETION DATE {B 122} a. "Place patient on assault precaution to prevent harm to peers/staff from aggressive behavior per physician's order." b. "If patient exhibits aggressive or threatening behavior, redirect patient by verbal de-escalation." c. "Question patient directly to determine whether patient has any impulses to assault others." These were routine, generic discipline functions and were not individualized. 6. Patient A6 (Master Treatment Plan dated 11/20/17) had the following nursing interventions for the problem, "Danger to Others, increase risk of assault to due to acute psychosis, erratic behavior and impulsivity": a. "Place patient on assault precaution to prevent harm to peers/staff from aggressive behavior per physician's order." b. "If patient exhibits aggressive or threatening behavior, redirect patient by 1:1 talk removed from environment, encourage use of coping skills." c. "Question patient directly to determine whether patient has any impulses to assault others." These are routine, generic discipline functions and were not individualized. 7. Patient A7 (Master Treatment Plan dated 11/20/17) had the following nursing interventions for the problem, "Danger to Self [with] plan to [overdose] on drugs": FORM CMS-2567(02·99) Previous Versions Obsolete Event ID: B02C 12 Facility ID. IL HOSP5915 If continuation sheet Page 10 of 23 PRINTED: 06/11/2018 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: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION R 11/30/2017 B. WING 144040 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (XJ) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 10 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X51 COMPlETION DATE {B 122} a. "Place patient on Suicide Precaution to prevent self-harm/suicidal behavior per physician's order." b. "Observe for behavior indicative of suicidal ideation, and ask direct questions to determine suicidal intent, plans for suicide, and means to commit suicide-" c. "If patient had intent to overdose, check for cheeking/palming medications and explain to patient rationale." d . "Conduct room checks for sharps/contraband/excessive linen and explain to patient rationale." These are routine, generic discipline functions and were not individualized. 8. Patient AS (Master Treatment Plan dated 11/22/17) had the following nursing interventions for the problem, "Danger to Self, with plan to [overdose] on meds": a. "Place patient on Suicide Precautions to prevent self-harm/suicidal behavior per physician's order." b. "Observe for behavior indicative of suicidal ideation, and ask direct questions to determine suicidal intent, plans for suicide, and means to commit suicide." c. "If patient had intent to overdose, check for cheeking/palming medications and explain to patient rationale." d. "Conduct room checks for FORM CMS-2567(02-99) Previous Versions Obsolete Event JD:B02C12 FadityJD: L HOSP5915 If continuation sheet Page 11 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDERISUPPUER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTfON A. B U I L D I N G - - - - - - - - R 11/30/2017 B. WING 144040 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL {X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 11 sharps/contraband/excessive linen and explain to patient rationale." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION OATE {B 122} These were routine, generic discipline functions and were not individualized. 9. Patient A9 (Master Treatment Plan dated 11/21/17) had the following nursing interventions for the problem, "Danger to Self, [Suicidal Ideation] [with] no plan, impulsive behavior": a. "Place patient on Suicide Precaution to prevent self-harm/suicidal behavior per physician's order." b. "Observe for behavior indicative of suicidal ideation, and ask direct questions to determine suicidal intent, plans for suicide, and means to commit suicide." c. "If patient had intent to overdose, check for cheeking/palming medications and explain to patient rationale." d. "Conduct room checks for sharps/contraband/excessive linen and explain to patient rationale." These were routine, generic discipline functions and were not individualized. 10. PatientA10 (Master Treatment Plan dated 11/22/17) had the following nursing interventions for the problem, "Danger to Others, [patient] slapped roommate during an argument": a. "Place patient on assault precaution to prevent harm to peers/staff from aggressive behavior per physician's order." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B02C12 Facifity ID: IL HOSP5915 If continuation sheet Page 12 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPUERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTR UCT ION A. B U I L D I N G - - - - - - - - R 11/30/2017 B. WING 144040 STREET ADDRESS, CITY, STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 122} Continued From page 12 b. "If patient exhibits aggressive or threatening behavior, redirect patient by encouraging verbalization of concerns." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS} COMPLETION DATE {B 122} These were routine, generic discipline functions and were not individualized. B. Policy Review The facility policy titled "Treatment Planning" (last reviewed November 2014) stated, "Master Treatment Plan goals will utilize an inventory of the patient's strengths, and list specific interventions individualized to the patient." The facility did not adhere to their policy regarding specific, individualized treatment interventions for each patient. C . Interview On 11/29/17 at 1:30 p.m., the Director of Nursing agreed that nursing interventions were not individualized. {B 124} TREATMENT PLAN CFR(s): 482.61(c)(1)(v) {B 124} The written plan must include adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to ensure that registered nurses and social workers adequately documented active treatment interventions on the Master Treatment Plan and unit schedule to show detailed and FORM CMS-2567(02-99) PreviOUS Versions Obsolete Event ID B02C t 2 Facility ID: IL HOSP5915 If continuation sheet Page 13 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: - 144040 OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION R 11/30/2017 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED · A BUILDING-------- DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 124} Continued From page 13 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (XSI COMPLETION DATE {B 124} comprehensive information about treatment for five (5) of 10 active sample patients (A1, A3, A4, A6, and A7). Specifically, documentation did not consistently include the patients' attendance or non-attendance, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. Findings include: A. Record Review The master treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (8/4/17), A2 (8/11/17), A3 (7/31/17), A4 (8/4/17), A5 (8/11/17), A6 (7/31/17), A7 (8/1/17), A8 (8/9/17, A9 (8/8/17), and A10 (8/9/17). This review revealed the following findings regarding assigned treatment interventions to psychiatrists (MD), registered nurses (RN), social workers (SW), and activity therapists {AT). 1. MD Interventions: a. Four patients (date of admission in parenthesis) A3 (7/28/17), A4 (8/2/17), A6 (7/31/17), and A7 (7/31/17) had the identically or similarly worded MD intervention: "Monitor and educate precautions, risks, benefits and side effects of medications during each visit or discuss FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: B02C12 Facility ID: IL HOSP5915 If continuation sheet Page 14 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) WLTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - R B. WING 144040 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG 11/30/2017 STREET ADDRESS. CITY, STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 124} Continued From page 14 possible medication options." The frequency was "Five X [times] per week." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIAT E DEFICIENCY) ID PREFIX TAG (XS) COMPlETION DATE {B 124} A review of progress notes from 8/7/17 through 8/15/17 were reviewed and revealed that there were no treatment notes reflecting that the MD provided education regarding medications for these patients. There was no documentation about the number and duration of contacts with patients. In addition, there was no documentation to show the patient's response to interventions. including the level of participation, behaviors exhibited, and specific comments made during interventions. 2 . Social Worker Interventions A review of progress notes from 8/7/17 through 8/16/17 revealed that there were no treatment notes reflecting that the SW provided the following interventions assigned on MTPs. There was no documentation about the number of contacts or attempts to provide active treatment interventions identified on MTPS for the interventions below. In addition, there was no documentation to show the patient's response to interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions. a. PatientA1 and A3- "Teach coping skills to assist the patient in effectively managing intense emotion and tolerating distress." Patient A7''Teach coping skills to assist the patient in affectively [sic] managing feelings of hopelessness." b. Patient A 1 - "Teach patient psychoeducation about importance of the compliance with FORM CMS-2567(02-99) Previous VerSions Obsolete Event ID: B02C12 Facility ID: IL HOSP5915 If continuation sheet Page 15 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER:· OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION R 11/30/2017 B. WING 144040 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED · A. B U I L D I N G - - - - - - - - DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 124} Continued From page 15 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5[ COMPLETION DATE {B 124} medication." c. Patient A3 and A4 - "Therapists will assist pt. [patient] in identifying 2-3 triggers and/or stressors in being (sic) a danger to others." 3. Nursing Interventions: A review of progress notes from 8/7/17 through 8/16/17 revealed that there were no treatment notes reflecting that the RNs provided the following interventions assigned on MTPs. There was no documentation about the number of contacts or attempts to provide active treatment interventions identified on MTPS for the interventions below. In addition, there was no documentation to show the patient's response to interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions. a. Patient A 1, A3, and A6- "Provide individual and/or group counseling." "Teach patient to use coping mechanism (sic) appropriately to adapt more effectively with stress and anger." Frequency was listed as "Ongoing" b. Patient A7 - "Teach patient to identify triggers or stressors related to sexually acting out, if experiencing urges." Frequency was "as needed." There was no documented treatment notes and documentation to show that nursing staff determined that the patient needed teaching sessions regarding triggers related to sexually acting out. 4. In addition to lack of documentation of nursing interventions identified on MTPs, there was no documentation of the nursing group titled, "Medication Education ... "identified on unit program schedules for active sample patients A1, FORM CMS-2567(02·99) Previous Versions Obsolete Event ID:B02C12 Facility ID: IL HOSP5915 If continuation sheet Page 16 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - R B. WING 144040 NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 11/30/2017 STREET ADDRESS, CITY, STATE, ZIP CODE DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 124} Continued From page 16 A3, A4, A6, and A7. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X51 COMPLETION DATE {B 124} B. Interview 1. In an interview on 8/15/17 at 11:10 a.m. with RN1, a Medication Education group scheduled on Tuesday, Thursday, and Saturday scheduled from 5:45 - 6:30 p.m . was discussed. RN1 stated that this group was being provided by registered nurses but was unable to locate documented evidence whether active sam pie patient A5 had attended this group. 2. In an interview on 8/16/17 at 12:20 p.m. with the Director of Clinical Services/Social Work and Director of Quality Improvement, intervention statements on MTPS were discussed. They did not dispute the findings that there was no documented evidence that social work interventions on MTPs were not being provided or not. 3. ln an interview on 8/16/17 at 2 :45p.m., the Director of Nursing acknowledged that there was no documented evidence that nursing interventions on MTPs and the medication education group on unit schedules were being conducted by registered nurses. Based on record review, policy review and interview, the facility failed to ensure that registered nurses adequately documented in the treatment notes active treatment interventions from the Master Treatment Plan to show comprehensive information about treatment for six (6) of 10 active sample patients (A2, A3, A4, A8, A9, and A 10). Specifically, documentation did FORM CMS·2567(02-99) Previous Versions Obsolete Event ID: B02Cl2 Fad ty ID: ll HOSP5915 If continuation sheet Page 17 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIER/CUA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BULDING - - - - - - - - R 11/30/2017 B. WING 144040 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED · DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {8 124} Continued From page 17 not consistently include the patients' response to education interventions, including the understanding of the information provided and specific comments if any. This failure hindered the treatment team in determining the patients' response to active treatment interventions, evaluating if there were measurable changes in the patients' condition and revising the treatment plan when the patient did not respond to treatment interventions. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {B 124} Findings include: A. Record Review 1. Patient A2 (admitted 11/20/17) had no documentation of patient response to medication education completed on 11/25/17 at 9:30p.m. and on 11/27/17 at 2:15p.m. 2. PatientA3 (admitted 11/18/17) had no documentation of patient response to medication education completed on 11/27/17 at 4:30p.m. In addition, the Master Treatment Plan (dated 11/18/2017) had the following medical problem identified, "Diabetes as evidenced by: (patient] is on insulin [sic]." There were no nursing treatment notes documenting that the following nursing interventions were done: a. "RN will educate patient on diabetic care re: glucose monitoring, medication regimen and administration, and prevention of injury, infection and good dental, skin and foot care." The frequency was "weekly." b. "RN will educate patient on diabetic care re: the circulatory, neurological and visual complications that result from poorly controlled FORM CMS-2567(02·99) Previous Versions Obsolete Event ID: B02C12 Facil ty ID: IL HOSP5915 If continuation sheet Page 18 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - R B. WING 144040 NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG 11/30/2017 STREET ADDRESS, CITY, STATE, ZIP CODE DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 124} Continued From page 18 diabetes." The frequency was "weekly." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (X5) COMPLETION DATE {B 124} c. "RN will educate patient re: the importance of insulin or oral hypoglycemic and diet for disease control." The frequency was "weekly." d. "RN will educate patient re: the importance of routine exercise and stress management to maintain blood sugar control." The frequency was "weekly." e. "RN will educate patient on diabetic care re: the signs and symptoms and treatment of hypoglycemia and hyperglycemia." The frequency was "weekly." 3. PatientA4 (admitted 11/21/17) had no documentation of patient response to medication education completed on 11/23/17 at 5:00p.m. 4. Patient AS (admitted 11/22/17) had no documentation of patient response to medication education completed on 11/25/17 at 4:45p.m. and on 11/26/17 at 5:00p.m. 5. PatientA9 (admitted 11/21/17} had no documentation of patient response to medication education completed on 11/23/17 at 5:00p.m. and on 11/25/17 at 7:00p.m. 6. PatientA10 (admitted on 11/22/17) had no documentation of patient response to medication education completed on 11/25/17 at 5:15p.m., on 11/26/17 at 11:00 p.m. and on 11/28/17 at6:00 p.m. B. Pol icy Review The facility policy titled "Patient and Family Education" (last reviewed in November 2014) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:B02C12 Facility 10: IL HOSP5915 If continuation sheet Page 19 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: . 144040 OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ R 11/30/2017 B. WING STREET ADDRESS. CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX ·TAG (X3) DATE SURVEY COMPLETED DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 124} Continued From page 19 does not describe treatment note documentation requirements for patient and family education. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {B 124} C. Interview 1. On 11/29/17 at 10:05 a.m., RN 1 stated, "I don't see them here, specifically, • when asked to identify treatment notes that documented the diabetic teaching interventions. 2. On 11/29/17 at 1:30 p.m., the Director of Nursing agreed that the nursing treatment notes should include the patients' response to the interventions. {B 148} NURSING SERVICES CFR(s}: 482.62(d)(1) {B 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 observation, record review, and interview, the facility failed to provide adequate oversight to ensure the quality of nursing services. Specifically, the Director of Nursing failed to monitor to: I. Ensure that treatment plans delineated nursing interventions to address the specific treatment needs of seven (7} of 10 active sample patients (A1, A2, A3, A4, A6, A?, and A9). Instead, treatment plans included interventions that were routine, generic discipline functions or were patient goals. Despite each patient presenting FORM CMS-2567(02·99) PreviOus Versions Obsolete Event ID: B02C1 2 Facility 10: IL HOSP5915 If continuation sheet Page 20 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: OM8 NO 0938-0391 (X2) MULTIPLE CONSTRUCTION ST REET ADDRESS. CITY, STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL I R 11/30/2017 B. WING 144040 (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {8 148} Continued From page 20 with unique psychiatric, intervention statements were identical or similarly worded with no method of delivery identified (individual or group sessions). There were no nursing interventions on MTPs for three (3) of 10 active sample patients (AS, A8, and A10) to address presenting psychiatric problems. These deficiencies result in treatment plans that failed to reflect a comprehensive, integrated, and individualized nursing approaches to interdisciplinary treatment. (Refer to 8122} PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (XS) COMPLETION DATE {8 148} II. Ensure that registered nurses adequately documented active treatment interventions listed on the Master Treatment Plan and unit schedule to show detailed and comprehensive information about treatment for five (5) of 10 active sample patients (A1, A3, A4, A6, and A7). Specifically, there was no documented evidence of treatment notes to reflect patients' attendance or non-attendance in active treatment, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to 8124} Ill. Ensure that active treatment measures were provided for two (2) of 10 active sample patients (A1 and A4) who were unwilling or not motivated to attend or participate in active treatment groups. Specifically, there was an inadequate frequency and intensity of active treatment provided by FORM CMS-2567(02-99) Previous VersiQns Obsolete Event ID:B02C12 Fac ity 10: IL HOSP5915 If continuation sheet Page 21 of 23 PRINTED: 06/1112018 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) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: ' 144040 (X2) MULTIPLE CONSTRUCT ION A BUILDING _ _ _ _ _ _ __ R 11/30/2017 B. WING STREET ADDRESS, CITY, STATE, Z IP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG l X 3) DATE SURVEY COMPLETED - DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 148} Continued From page 21 registered nurses to assist with each patient's treatment goal attainment. Also, there was no documented evidence in the medical record to show attempts by registered nurse to engage these patients in active treatment interventions identified on MTPs or alternative active treatment measures when patients refused to participate. Failure to provide active treatment at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, thereby delaying their improvement. (Refer to 8125-1) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIC IENCY> ID PREFIX TAG (XS) COMPlETION DATE {B 148} Based on record review, policy review and interview, the facility failed to provide oversight to ensure the quality of nursing services. Specifically, the Director of Nursing failed to: I. Ensure that treatment plans delineated nursing interventions to address the specific treatment needs of 10 of 10 active sample patients (A 1, A2, A3, A4, A5, A6, A7, AB, A9, and A10). Instead, treatment plans included interventions that were routine, generic discipline functions. These deficiencies result in treatment plans that failed to reflect a comprehensive, integrated and individualized nursing approach to treatment. (Refer to 8122) II. Ensure that registered nurses adequately documented active treatment interventions listed on the Master Treatment Plan to show detailed and comprehensive information about treatment for six (6) of 10 active sample patients (A2, A3, A4, A8, A9, andA10). Specifically, there was no documented evidence of nursing treatment notes to reflect patients' response to interventions, including the understanding of the information provided and specific comments if any. This FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B02C12 Faclity ID; IL HOSP5915 If continuation sheet Page 22 of 23 PRINTED: 06/11/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMI:NT OF DEFICIENCIES AN[} PLAN OF CORRECTION (X1) PROVIGERISUPPLIERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {B 148} Continued From page 22 failure hindered the treatment team from determining the patients' response to active nursing interventions, evaluating if there were measurable changes in the patients' condition and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to 8124) FORM CMS-2567(02·99) Previous Versions Obsolete R 11/30/2017 B. WING 144040 (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED Event ID:B02C12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE {8 148} Facility 10: IL HOSP5915 If continuation sheet Page 23 of 23