The Centers for Medicare and Medicaid Services (CMS) determined that Hickory Trail Hospital failed to abide by records requirements for psychiatric hospitals related to treatment planning, the administration of medication and use of physical restraints on the Child and Adolescent Unit. Additionally, CMS found the hospital deficient in assessments, psychiatric evaluations, medical staff, and nursing services. Hickory Trail Hospital was found to be using Master Treatment Plans (MTPs) with pre-printed goals and interventions. A CMS review of eight sample patient records also revealed that the physician and nursing interventions included generic functions and “lacked any focus for treatment,” and that patient goals and interventions were not modified as treatments progressed. Nurses said that they were not able to attend treatment team meetings, because “we are giving meds at that time.” CMS also found that 5 out of 8 patients sampled had physician medication orders written on an “as needed basis,” which were unclear and ambiguous. These orders did not specify medication delivery methods (which could affect the dosage received) and allowed nurses to use their discretion in administering medications for non-specific purposes such as “agitation” or “psychosis.” CMS found that this practice not only results in nursing staff functioning outside their scope of practice, but it has “the potential for serious complications from improperly administered PRN medications.” In an interview, the Director of Nursing stated, “I believe we are too liberal in our medication ordering practices.” CMS also cited the facility for using “therapeutic holds” for pediatric and adolescent patients without following CMS guidelines for therapeutic use of restraint. The Director of Nursing stated that “They [the holds] are not considered restrictive if they are less than 5 minutes,” and “confirmed that no physician orders were obtained if these ‘therapeutic holds’ lasted less than 5 minutes.” Finally, CMS found that the facility failed to ensure that children under 12 were provided safe, secure sleeping quarters separate from adolescents. It was found that a 10 year old male resided in a 4-patient bedroom with 12, 14, and 16 year old males. CMS wrote, “Failure to provide separate sleeping quarters for child and adolescent patients potentially compromises the younger child’s safety and is incongruent with the growth and developmental needs of both children and adolescents.” As a result of these citations, the Hickory Trail Hospital was required to submit a plan of correction to address its deficiencies.