HospitalInspections.org

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

I. Ensure that Master Treatment Plans (MTPs) were based on an inventory of strengths that reflected each patient's specific assets or personal attributes that could be used to formulate treatment goals and active treatment interventions for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The failure to identify patient strengths can adversely affect clinical decision-making in formulating MTPs and impairs the treatment team's ability to develop individualized treatment goals and interventions. (Refer to B119).

II. Ensure MTPs contained individualized and patient-related short-term goals written in observable, measurable, and behavioral terms for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The goals were not specific and/or described routine hospital functions which did not define areas of patient improvement. In addition, some goals lacked time frames. Goal statements failed to give specific focus to treatment, leading to fragmentation of care. (Refer to B121).

III. Develop MTPs that identified treatment interventions that provided a focus that addressed each patient's individual needs for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The interventions on the plans were generic, job description modalities which were frequently identical between records. This deficiency resulted in a failure to guide treatment staff to achieve measurable and behavioral outcomes. (Refer to B122).

IV. Ensure that registered nurses documented detailed and comprehensive treatment notes for psychiatric interventions in the Master Treatment Plan for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, treatment notes were missing or lacked detailed information to show each patient's response to assigned psychiatric interventions. This failure hindered the treatment team from determining the patient's response to 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 B124).

V. Ensure that active treatment measures were provided for four of eight active sample patients (A2, A4, A7, and A8) 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 and no documentation to show attempts to engage these patients in alternative active treatment measures. Despite inconsistent or lack of regular attendance in groups, Master Treatment Plans (MTP) were not revised to reflect alternative treatment measures to assist patients in making an appropriate recovery. Failure to provide active treatment at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, potentially delaying their improvement or resulting in their being discharged without the necessary skills to prevent relapse. (Refer to B125).

VI. Ensure that medical records contained progress notes written by social work staff. Specifically, for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8), the social work staff failed to document progress notes that contained information to address each patient's progress towards treatment goals, the clinical course of treatment, or improvement in identified psychiatric problems. The absence of comprehensive documentation of each patient's progress prevented a chronological picture of pertinent changes in the patient's psychiatric condition or overall responses to social work interventions related to active treatment. (Refer to B128).

VII. Ensure that medical records contained progress notes written by recreational therapy staff. Specifically, for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8), there were no progress notes written by recreational therapy staff to show each patient's progress towards treatment goals, clinical course of treatment, or improvement in identified psychiatric problems. The absence of comprehensive documentation of each patient's progress prevented a chronological picture of pertinent changes in the patient's psychiatric condition or overall responses to recreational therapy staff interventions related to active treatment. (Refer to B129).

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) were based on an inventory of strengths that reflected each patient's specific assets or personal attributes that could be used to formulate treatment goals and active treatment interventions for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The failure to identify patients 'personal strengths can adversely affect clinical decision-making in formulating MTPs and impairs the treatment team's ability to develop individualized goals and interventions.

Findings include:

A. Record review

1. Patient A1's MTP, dated 10/28/19, included the following deficient patient strength statements: "Social Security Income, Medicare." These statements were not descriptive of personal attributes. They did not include how the strengths identified could be used to assist the patient in managing presenting psychiatric symptoms during hospital treatment. The statement did not describe personal interests, skills, or accomplishments (except associate degree) that could be used to plan active treatment interventions.

2. Patient A2's MTP, dated 11/1/19, included the following deficient patient strength statements: "Supportive family and friends; [s/he] is employed and has health insurance." These statements did not describe supportive family and friends and employment. Also, they did not include how the strengths identified could be used to assist the patient in managing presenting psychiatric symptoms during hospital treatment. The statement did not describe personal interests, skills, or accomplishments (except college education) that could be used to plan active treatment interventions.

3. Patient A3's MTP, dated 11/1/19, included the following deficient patient strength statements: "Able to communicate needs, Medicare." These statements were not behaviorally descriptive of personal attributes. They did not include how the strengths identified could be used to assist the patient in managing presenting psychiatric symptoms during hospital treatment. The statement did not describe personal interests, skills, or accomplishments (except high school graduation) could be used to plan active treatment interventions.

4. Patient A4's MTP, dated 10/26/19, included the following deficient patient strength statements: "Able to communicate wants and needs clearly, ADL's." These statements were not descriptive of personal attributes. They did not include how the strengths identified could be used to assist the patient in managing presenting psychiatric symptoms during hospital treatment. The statement did not describe personal interests, skills, or accomplishments that could be used to plan active treatment interventions.

5. Patient A5's MTP, dated 10/31/19, included the following deficient patient strength statements: "has some supports, open to mental health treatment, motivated to find employment, recognizes [his/her] responsibility to [his/her] son and step kids." These statements were not descriptive of personal attributes. They did not include how the strengths identified could be used to assist the patient in managing presenting psychiatric symptoms during hospital treatment. The statement did not describe personal interests, skills, or accomplishments that could be used to plan active treatment interventions such as interest in music and skills in playing guitar.

6. Patient A6's MTP, dated 11/1/19, included the following deficient patient strength statements:
"Able to express needs and concerns, services through [Name of Mental Health Center] ... Has Medicaid." These statements were not behaviorally descriptive. There was no explanation of how the strengths identified could be used to assist the patient in improving presenting psychiatric symptoms during hospitalization. The statement did not describe personal attributes, skills, or accomplishments (except for completed high school) that could be used to plan active treatment interventions.

7. Patient A7's MTP, dated 8/22/19, included the following deficient patient strength statements: "Has a guardian. Medicare, Medicaid, SSD [Social Security, and SSI [Supplemental Security Income] to assist with paying for medications, housing, and treatment." These statements were not descriptive of personal attributes. There was no explanation of how the strengths identified could be used to assist the patient in improving presenting psychiatric symptoms during hospitalization. The statement did not describe skills, interests, or accomplishments that could be used to plan active treatment interventions.

8. Patient A8's MTP, dated 10/24/19, included the following deficient patient strength statements: "Has been cooperative with treatment since admission; reports desire for substance use treatment." These statements were not descriptive of personal attributes. There was no explanation of how the strengths identified could be used to assist the patient in improving presenting psychiatric symptoms during hospitalization. The statement did not describe personal attributes, skills, or accomplishments that could be used to plan active treatment interventions.

B. Interviews:

1. In an interview on 11/5/19 at 12:15 p.m. and on 11/6/19 at approximately 9:30 a.m., the Director of Nursing did not refute the findings that several strengths identified could not be used to develop interventions to implemented during hospitalization.

2. In an interview on 11/6/19 at approximately 10:50 a.m. with the Director of Social Work, the strength statements in the MTPs were discussed. She stated she believed that some of the statements were personal strengths. However, she did admit that statements such as the patients having Medicaid, SSI, or SSD were not personal strengths.

Based on record review, policy review and interview, the facility failed to provide Master Treatment Plans (MTPs) that identified patient related short-term goals in observable, measurable, and behavioral terms for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The goals were not specific and/or described routine hospital functions which did not define areas of patient improvement. In addition, some goals lacked time frames. Goal statements failed to give specific focus to treatment, leading to fragmentation of care.

Findings include:

A. Record Review

1. Patient A1's MTP (dated 10/28/19) had the following short-term goals for the identified problem, "[Patient] experiencing auditory and visual hallucinations. Admits to using meth and marijuana":
"[Patient] will take medications as prescribed without objection."
"[Patient] will talk with staff if having upsetting thoughts/fears."
"[Patient] will identify at least 3 reasons to continue taking medications in the community."

There were no time frames noted for completion of the goals. These goals were not specific or expressed in behavioral, measurable terms.

2. Patient A2's MTP (dated 11/1/19) had the following short-term goals for the identified problem: "[Patient] was seeing things others could not see, believing things others would not, and was being aggressive":
"[Patient] will take medications as prescribed."
"[Patient] will communicate with others in a way that makes sense."
"[Patient] will have no threats or attempts to harm self or others."

These goals were not specific or expressed in behavioral, measurable terms.

3. Patient A3's MTP (dated 11/1/19) had the following short-term goals for the identified problem: "[Patient] reported fear of losing control with thoughts of harming others and self':
"[Patient] will talk with staff when having thoughts to harm self or others."
"[Patient] will take medications as prescribed."
"[Patient] will not engage in life-threatening harm to self or others."

These goals were not specific or expressed in behavioral, measurable terms.

4. Patient A4's MTP (dated 10/26/19) had the following short-term goals for the identified problem: "became threatening towards multiple others in the community, was not taking medications":
"[Patient] will take medications as prescribed without objection."
"[Patient] will talk with staff when upset rather than engage in threatening and physically aggressive behaviors."

These goals were not specific or expressed in behavioral, measurable terms.

5. Patient A5's MTP (dated 10/31/19) had the following short-term goals for the identified problem: "[Patient] hung self and had to be cut down by [patient's] sister, has not been taking any medication":
"[Patient] will take all medications as prescribed."
"[Patient] will identify and demonstrate 3 coping skills to manage stressors."
"[Patient] will identify 3 reasons to avoid drug use."
"[Patient] will speak with staff should any distressing thoughts arise including thoughts of suicide."

These goals were not specific or expressed in behavioral, measurable terms.

6. Patient A6's MTP (dated 11/1/19) had the following short-term goals for the identified problem, "[Patient] disclosed suicide ideation with plan and intention. Reported thoughts to jump off a bridge":
"[Patient] will take medications as prescribed without objection."
"[Patient] will refrain from physical aggression toward others."
"[Patient] will not engage in any life-threatening self-harm."
"[Patient] will identify 3 coping skills to manage distressing thoughts."

These goals were not specific or expressed in behavioral, measurable terms.

7. Patient A7's MTP (dated 8/23/19) had the following short-term goals for the identified problem: "[Patient] stopped taking medications, threatened to punch, kill staff":
"[Patient] will take medications as prescribed with no more than 3 prompts."
"[Patient] will make wants and needs know [sic] to staff."
"[Patient] will talk to staff when upset without threats."

These goals were not specific or expressed in behavioral, measurable terms.

8. Patient A8's MTP (dated 10/24/19) had the following short-term goals for the identified problem, "[Patient] took a bottle of pills in a suicide attempt, was aggressive towards law enforcement and hospital staff":
"[Patient] will talk with staff should [patient] have thoughts to harm self.
"[Patient] will talk to staff should [patient] have thoughts to harm others."
"[Patient] will identify at least 3 benefits of sobriety."
"[Patient] will identify at least 3 safe/healthy ways to manage life stressors, depression, and suicidal thoughts."

These goals were not specific or expressed in behavioral, measurable terms.

B. Policy Review

The facility policy titled "Treatment Plan" with the effective date of May 8, 2017, stated: "Quality mental health services are directed by focused, individualized Treatment Plans based on comprehensive assessment of the individual's needs and assets."

C. Interviews

1. On 11/5/19 at 11:00 a.m., RN 2 agreed that the short-term goals were not individualized or measurable.

2. On 11/5/19 at 12:15 p.m., the interim Director of Nursing (DON) concurred that the goals were not specific or measurable.

3. On 11/5/19 at 3:15 p.m., the MTPs for the active sample patients were discussed, the Medical Director acknowledged that some of the goal statements were compliance issues, not patient-oriented outcomes. She also agreed that several short-term goals were not measurable.

4. On 11/5/19 at 4:10 p.m., the Director of Social Work agreed that the short-term goals were not individualized or measurable.

Based on record review, policy review and interview, the facility failed to develop MTPs that identified treatment interventions that provided a focus that addressed each patient's individual needs for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The interventions on the plans were generic, job description modalities which were frequently identical between records. This deficiency resulted in a failure to guide treatment staff to achieve measurable and behavioral outcomes.

Findings include:

A. Record Review

1. Patient A1 (MTP dated 10/28/19) had the following interventions:

Nursing:
a. "Nursing staff will meet with [patient] for at least 5 minutes each shift when [patient] is awake to encourage [patient] to take medications as prescribed and to talk to staff if hearing voices or experiencing upsetting thoughts."

b. "Nursing staff will encourage [patient] to identify at least 3 negative effects of substance use and at least 3 reasons to continue taking medications in the community."

Social Work:
a. "At least twice a week, Social worker will speak with [patient], Four County Mental Health, and any authorized individuals to arrange for recommended outpatient services including case management, medication management, and substance abuse counseling."

b. "Clinical Therapist will provide Mood Management group 2 days per week for 60 minutes to identify and discuss symptoms such as hearing voices and thinking other are shooting lasers."

c. "Clinical Therapist will provide Interactive Group 3 days per week for 60 minute sessions to encourage focused attention on reality based activities and improve ability to talk with others in a clear manner."

d. "Clinical Therapist will offer Dual Diagnosis Group 2 days a week for 60 minute sessions to provide information and education about the negative effects substance use has on symptoms of mental illness and to assess current motivation for sobriety."

e. "Clinical Therapist will provide Brief Supportive Therapy Group 3 days a week designed to help [patient] talk about current treatment and barriers that contribute to inability to maintain stability in the outpatient setting."

f. "Clinical Therapist will help [patient] complete a Safety & Wellness Recovery Action Plan to help [patient] identify warning signs for relapse and prevent worsening of symptoms."

Activity Therapy:
a. "Activity Specialist will provide Physical Activity Group 4 days a week for 45 minute sessions to increase activity levels and improved management of mood."

b. "Activity Specialist will provide Recreation Participation Group 6 days a week for 60 minute sessions to enhance healthy leisure activities for management of mood."

c. "Activity Specialist will provide Relaxation and Coping Skills Group 2 days a week for 60 minute sessions to increase relaxation response and apply therapeutic activities to deal with life stressors."

d. "Activity Specialist will provide Creative Expressions Group 2 days a week for 60 minute sessions to facilitate healthy ways to communicate thoughts and feelings using art, as self-directed."

e. "Activity Specialist will provide Leisure Awareness Group 1 day a week for 60 minute sessions to increase leisure interests and preferences and learn healthy ways to use leisure time."

f. "Activity Specialist will provide Functional Leisure Skills Group 2 days a week for 60 minute sessions to improve social behaviors and emotion regulation while engaging with others during leisure time."

g. "Activity Specialist will provide Social Circle group 1 day a week for 60 minute sessions to improve self-esteem and acquire skills for establishing and maintaining meaningful and healthy relationships."

h. "Activity Specialist will provide Independent Living Skills Group 1 day a week for 60 minute sessions designed to create a healthy leisure lifestyle plan by discharge."

These interventions were not specific in addressing the individual's needs.

2. Patient A2 (MTP dated 11/1/19) had the following interventions:

Nursing
"Nursing staff will meet with [patient] for at least 5 minutes each shift when [patient] is awake to encourage [patient] to take his medications as prescribed and talk with staff if feeling fearful or confused. Nursing staff will orient [patient] to the date and surroundings as needed."

Social Work
a. Clinical Therapist will offer Brief Supportive therapy group 3 days a week for 60 minute sessions to encourage [patient] to talk about treatment goals, progress in recovery and to develop a Safety and Wellness Recovery Action Plan to maintain stability in the outpatient setting."

b. "Clinical Therapist will offer Dual Diagnosis Group 2 days a week for 60 minute sessions to provide information and education about the negative effects substance use has on symptoms of mental illness and to assess current motivation for sobriety."

c. "Clinical Therapist will provide Interactive Group 3 days per week for 60 minute sessions to encourage focused attention on reality based activities and improve ability to talk with others in a clear manner."

d. "Clinical Therapist will offer Mood Management Group 2 days a week for 60 minute sessions to help [patient] learn skills for safely expressing and managing emotions in a calm, non-threatening and non-harmful manner."

e. "Clinical therapist will meet with [patient] on a weekly basis to complete a Columbia Suicide Severity Assessment to determine current thoughts of suicide and will develop a Safety and Wellness Recovery Action Plan to facilitate stability upon discharge."

f. "At least twice a week, Social Worker will speak with [patient] and any authorized contacts regarding continuum of care outpatient mental health services with recommendations for case management and substance abuse counseling."

Activity Therapy
a. "Activity Specialist will provide Physical Activity Group 4 days a week for 45 minute sessions to increase activity levels and improved management of mood."

b. "Activity Specialist will offer Functional Leisure Skills group 2 days a week for 60 minute sessions to improve social behaviors, focus, and ability to follow directions to be able to engage with others during leisure activities."

c. "Activity Specialist will offer Social Circle group 1 day a week for 60 minute sessions to facilitate social interaction skills and socially acceptable behaviors."

These interventions were not specific in addressing the individual's needs.

3. Patient A3 (MTP dated 11/1/19) had the following interventions:

Nursing
"Nursing Staff will meet with [patient] at least 5 minutes each shift when [patient] is awake to encourage [patient] to communicate with others in a calm, respectful manner and not threaten to attempt to harm self or others."

Social Work
a. "At least twice a week, Social worker will speak with [patient], ComCare Mental Health, and any authorized individuals to arrange for continuum of care, outpatient mental health services with recommendations for crisis case management, medication management, and substance abuse counseling."

b. "Clinical Therapist will offer Dual Diagnosis Group 2 days a week for 60 minute sessions to provide information and education about the negative effects substance use has on symptoms of mental illness and to assess current motivation for sobriety."

c. "Clinical Therapist will provide Cognitive Therapy group 3 days a week for 60 minute sessions to help [patient] learn healthy coping strategies to manage symptoms of unstable mood and impulsive behaviors."

d. "Clinical Therapist will meet with [patient] on a weekly basis to complete a Columbia Suicide Severity Assessment to determine current thoughts of suicide and will develop a Safety and Wellness Recovery Action Plan to assist [patient] upon discharge."

e. Clinical Therapist will offer Brief Supportive therapy groups 3 days a week for 60 minute sessions to encourage [patient] to talk about treatment goals, progress in recovery and to develop a Safety and Wellness Recovery Action Plan to utilize to maintain stability in the outpatient setting."

Activity Therapy
a. "Activity Specialist will provide Physical Activity Group 4 days a week for 45 minute sessions to increase activity levels and improved management of mood."

b. "Activity Specialist will provide Relaxation and Coping Skills Group 2 days a week for 60 minute sessions to increase relaxation response and apply therapeutic activities to deal with life stressors."

c. "Activity Specialist will offer Creative Expressions group 1 day a week for 60 minute sessions to facilitate healthy ways for [patient] to communicate thoughts and feelings using art, as self-directed."

d. "Activity Specialist will provide Recreation Participation Group 6 days a week for 60 minute sessions to enhance healthy leisure activities for management of mood."

e. "Activity Specialist will offer Leisure Awareness group 1 day a week for 60 minute sessions for [sic] to increase leisure interests and overcome boredom."

f. "Activity Specialist will offer Independent Living Skills group 1 day a week for 60 minute sessions to address need to improve activities of daily living and improve ability to take care of self in the community."

g. "Activity Specialist will offer Functional Leisure Skills group 2 days a week for 60 minute sessions, to improve behaviors, focus and ability to follow directions."

h. "Activity Specialist will offer Social Circle group 1 day a week for 60 minute sessions to facilitate social interaction skills and socially acceptable behaviors."

These interventions were not specific in addressing the individual's needs.

4. Patient A4 (MTP dated 10/26/19) had the following interventions:

Nursing
"Nursing Staff will speak with [patient] daily for at least 5 minutes each shift [patient] is awake to encourage [patient] to take medications as prescribed without objection. Nursing will encourage [patient] to identify at least two coping strategies that [patient] can use when angry instead of threatening others."

Social Work
a. "Clinical Therapist will provide Interactive therapy Group 3 days per week for 60 minute sessions to help provide [patient] opportunities to talk with others in a calm and non-threatening manner."

b. "Clinical Therapist will provide Brief Supportive therapy group 3 days a week for 60 minutes to help [patient] identify symptoms [patient] struggles with and how to manage these in a healthy manner."

c. "Clinical Therapist will provide Mood Management Therapy group 2 days a week for 60 minutes to help [patient] develop positive strategies to manage anger without becoming loud, threatening, or physically aggressive towards others."

d. "At least twice a week, Social Worker will speak with [patient], Four County MHC [mental health center], Montgomery County jail, and any authorized contacts regarding hold order to return to jail upon discharge and outpatient mental health services. Recommended services include medication management and case management."

Activity Therapy
a. "Activity Specialist will provide Physical Activity group 4 days a week for 45 minutes to help [patient] participate in physical activity and acquire positive benefits."

b. "Activity Specialist will provide Leisure Awareness group 1 day a week for 60 minutes to help [patient] learn how to use leisure time to gain benefits of healthy lifestyle."

c. "Activity Specialist will provide Creative Expressions group 1 day a week for 60 minutes to help [patient] engage in art activities."

d. "Activity Specialist will provide Relaxation and Coping Skills Group 2 days a week for 60 minute sessions to increase relaxation response and apply therapeutic activities to deal with life stressors."

e. "Activity Specialist will offer Functional Leisure Skills group 2 days a week for 60 minute sessions, to improve social behaviors, communication skills, and emotional regulation."

f. "Activity Specialist will provide Social Circle group 1 day a week for 60 minutes to help [patient] interact and communicate with others in a way that makes sense."

g. "Activity Specialist will provide Recreation Participation group 6 days a week for 60 minutes to participate in health leisure activities for manage [sic] of [patient's] mood."

h. "Music therapist will offer Music and Performance group 2 days a week for 60 minute sessions to acquire skills using music for coping skills and recreation activities."

i. "Music Therapist will offer Music Therapy and Relaxation group 2 days a week for 60 minute sessions to increase motivation."

These interventions were not specific in addressing the individual's needs.

5. Patient A5 (MTP dated 10/31/19) had the following interventions:

Nursing
a. "Nursing staff will meet with [patient] each shift while awake for 5-10 minutes as tolerated. Will encourage [patient] to talk to staff if having any thoughts of harming self, and will encourage [patient] to identify coping skills to manage stressors, identify 3 reasons to avoid street drugs."

b. "Nursing staff will meet with [patient] 10-15 minutes 1 day per week to educate regarding medication compliance to manage mood as well as negative impact of street drugs on mental health."

Social Work
a. "Therapist will meet with [patient] on a weekly basis to complete the Columbia Suicide Severity Rating Scale (Since Last Contact) to evaluate for thoughts of wanting to end [patient's] life."

b. "At least twice a week, Social Worker will speak with [patient], Elizabeth Layton Center, and any authorized contacts regarding discharge planning and outpatient mental health services. Recommended outpatient services include medication management and individual therapy."

c. "Therapist will provide Brief Supportive Group for 3 days a week for 60 minutes to assist [patient] to discuss progress in treatment and healthy ways to manage mental health needs in the community."

d. "Clinical Therapist will provide Cognitive Therapy Group 2 days a week to help [patient] learn to manage thoughts and feelings that contribute to impulsive behaviors, such as try to kill self."

Activity Therapy
a. "Activity Specialist/Recreation Therapist will provide Physical Activity 4 days a week for 45 mins each session for [patient] to acquire benefits of physical activity participation to overall health."

b. "Activity Specialist/Recreation Therapist will provide Leisure Awareness 1 day a week for 60 mins each session to increase [patient's] understanding of the importance of leisure and the impact of leisure choices and preferences to overall health."

c. "Activity Specialist/Recreation Therapist will provide Independent Living Skills 1 day a week for 60 mins to help [patient] acquire activities of daily living skills for [patient] to be able to maintain stability in community and avoid future hospitalizations."

d. "Activity Specialist/Recreation Therapist will provide Relaxation and Coping Skills Group 2 days a week for 60 minute sessions to increase relaxation response and apply therapeutic activities to manage."

e. "Activity Specialist/Recreation Therapist will provide Functional Leisure Skills 2 days a week for 60 mins each session to improve [patient's] communication skills, focus, and ability to follow directions to be able to engage with others and in leisure activities."

f. "Activity Specialist/Recreation Therapist will provide Social Circle 1 day a week for 60 mins to facilitate social activities to help [patient] increase self-esteem and acquire skills for establishing and maintaining meaningful and healthy relationships."

g. "Music Therapist will offer Music Improvisation group 2 days a week for 60 minute sessions to facilitate healthy ways to communicate feelings and thoughts using music, as self-directed.

h. "Music Therapist will offer Music and Performance group 2 days a week for 60 minute sessions to increase use of leisure time in a personal and rewarding manner with music."

These interventions were not specific for the individual's needs.

6. Patient A6 had the following interventions:

Nursing
a. "Nursing will meet with [patient] every shift while awake for 5-10 minutes to monitor mood and behaviors. Will monitor for signs of becoming upset such as looking intense, pacing, cursing. Will encourage [patient] to talk with staff, write in journal, read magazine or book to manage stress. Will also encourage [patient] to identify 3 coping skills to manage distressing thoughts."

b. "Nursing will provide nursing education 2 days per week for 5-10 minutes to educate about medications and benefits of compliance, as well as coping skills to manage self-harming thoughts."

Social Work
a. "Therapist will provide Brief Supportive group therapy 3 days per week 60 minutes per session to help [sic] positive strategies to manage self-harm and suicide without acting on those thoughts."

b. "Therapist will assess suicide risk with screening tool on a weekly basis."

c. "Therapist will speak with [patient], Four County MHC, or authorized others at least twice per week to arrange for outpatient mental health services such as case management, therapy, and medication management."

Activity Therapy
a. "Activity Specialist/Recreation Therapist will provide Physical Activity 4 days a week for 45 mins each session for [patient] to acquire benefits of physical activity participation to overall health."

b." Activity Specialist/Recreation Therapist will provide Social Circle 1 day a week for 60 mins to facilitate social activities to help [patient] increase self-esteem and acquire skills for establishing and maintaining meaningful and healthy relationships."

c. "Activity Specialist/Recreation Therapist will provide Relaxation and Coping Skills Group 2 days a week for 60 minute sessions to increase relaxation response and apply therapeutic activities to manage."

d. "Activity Specialist/Recreation Therapist will offer Recreation Participation 6 days a week for 60 mins each session to increase participation in structured leisure activities."

e. "Activity Specialist/Recreation Therapist will provide Functional Leisure Skills 2 days a week for 60 mins each session to improve [patient's] communication skills, focus, and ability to follow directions to be able to engage with others and in leisure activities."

These interventions were not specific for the individual's needs.

7. Patient A7 (MTP dated 8/22/19) had the following interventions:

Nursing
a. "Nursing Staff will meet with [patient] for 5-10 minutes each shift [patient] is awake and orient to treatment, encourage [patient] to talk to staff should [patient] feel upset or have thoughts to harm others. Nursing Staff will encourage [patient] to attend to his daily hygiene such as showering and wearing clean clothing."

b. "Nursing Staff will watch for signs that [patient] is becoming upset such as pacing, getting very quiet, and will encourage [patient] to meditate, journal, read a book, or go to a quiet location to calm"

Social Work
a. "At least twice per week, Social Worker will talk with [patient], the guardian, ComCare, or any authorized others to discuss [patient's] ability to care for self and to manage thoughts and mood without aggression. Social Worker will assist with looking into placement options at other Nursing Facilities for Mental Health to assure that mental needs are cared for."

b. "Therapist will provide Brief Supportive Group for 60 minutes, 3 days a week, to encourage [patient] to talk about why [patient] was hospitalized, current treatment progress, and the importance of following through with medications to manage mental health."

c. "Therapist will provide Interactive Group for 60 minutes, 4 days a week to help focus [patient's] attention on the here and now and to encourage [patient] to talk to others in a focused, on topic manner."

d. "Therapist will provide Mood Management Therapy for 60 minutes, 1 day a week to help [patient] learn safe ways to manage and express thoughts and feelings without destroying property or threatening to harm others."

Activity Therapy
a. "Activity Specialist will provide Independent Living Skills 1 day a week for 60 mins to help [patient] address lack of activities of daily living skills related to leisure for [patient] to be able to take care of self in the community."

b. "Activity Specialist will provide Functional Leisure Skills 2 days a week for 60 mins each session to improve orientation, attention span, and concentration abilities to be able to participate in productive leisure activities."

c. "Activity Specialist will provide Social circle 1 day a week for 60 mins to help [patient] communicate wants and needs in a clear manner to be able to advocate for self."

d. "Activity Specialist will offer Recreation Participation 6 days a week for 60 mins each session to increase participation in structured leisure activities."

These interventions were not specific for the individual's needs.

8. Patient A8 (MTP dated 10/24/19) had the following interventions:

Nursing
"Nursing will meet with [patient] at least 5 minutes each shift when [patient] is awake to encourage [patient] to talk to staff if feeling depressed, has thoughts to harm/kill self and encourage [patient] to identify at least 3 benefits of sobriety and at least 3 healthy coping strategies to manage depression and suicidal thoughts. Nursing staff will watch for signs that [patient] is becoming upset such as pacing, talking loud or fast and will encourage [patient] to talk with staff or go to a quiet location to calm."

Social Work
a. "Therapist will meet with [patient] at least once a week to complete Columbia Suicide Severity Rating Scale to assess [patient] for suicide ideation. Therapist will assist [patient] with developing a safety plan to utilize to help manage current life stressors, depression, and potential suicidal thoughts prior to discharge."
b. "Therapist will provide Brief Supportive Therapy 3 day a week for 60 minutes to encourage to reflect on and discuss behaviors that led to admission, current treatment and plans to manage life stressors and depression in the community."

c. "Therapist will provide Cognitive Group for 4 days a week for 60 minutes to help [patient] learn safe and appropriate ways to manage and express depression, negative thoughts, and current life stressors."

d. "Therapist will provide Dual Diagnosis Group for 2 days a week for 60 minutes each session [to] support goals for long-term sobriety and learn alternative strategies to deal with life stressors other than substance use."

e. "At least twice a week, Social Worker will talk to [patient], ComCare and authorized others to coordinate discharge plans, assist with looking into placement options, and arrange for follow up services such as substance use treatment, therapy, case management, and medication management."

These interventions were not specific for the individual's needs.

Activity Therapy
There were no Activity Therapy interventions on the treatment plan.

B. Policy Review

The facility policy titled "Treatment Plan" with the effective date of May 8, 2017 stated, "Quality mental health services are directed by focused, individualized Treatment Plans based on comprehensive assessment of the individual's needs and assets." The facility was not in compliance with this policy.

C. Interviews

1. On 11/5/19 at 11:15 a.m., RN 4 stated, "I see what you mean about individualization. We are working with staff on that."

2. On 11/5/19 at 12:15 p.m., the Interim Director of Nursing stated, "No, the interventions are not specific."

3. On 11/5/19 at 2:30 p.m., the Director of Recreational Therapy concurred that the activity therapy interventions were not individualized to address each patient's specific needs.

Based on record review and interview, the facility failed to ensure that registered nurses (RN) documented detailed and comprehensive treatment notes for the assigned psychiatric interventions in the Master Treatment Plans (MTPs) for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, treatment notes were missing or lacked detailed information regarding the patients' attendance or non-attendance in planned and scheduled active treatment sessions. RN documentation did not include specific topics or content discussed, the patients' behavior during interventions, the duration of contact, and their response to assigned nursing interventions. There was also a failure to include the level of participation, the level of understanding of the information provided, and specific patients' 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 MTPs for the following patients were reviewed (dates of plans in parentheses) for assigned interventions: A1 (10/28/19), A2 (11/1/19), A3 (11/1/19), A4 (10/26/19), A5 (updated 10/31/19), A6 (11/1/19), A7 (8/22/19; updated 10/29/19), and A8 (10/24/19). Registered Nurses (RN) Shift Notes and Nursing Education Notes from 10/27/19 through 11/4/19 were reviewed and revealed that there was limited or no documented evidence that assigned psychiatric interventions in the MTPs had been implemented by RNs. There was no documentation about the number of contacts and duration of contacts. The documentation also lacked detailed information about the topic discussed and how the patient responded to the treatment interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

1. Patient A1 had the following intervention statements for the psychiatric problem of "[Patient] experiencing auditory and visual hallucinations. Admits to using meth [methamphetamine] and marijuana": "Nursing staff will meet with [patient] for at least 5 minutes each shift when [patient] is awake to encourage [patient] to take medications as prescribed and to talk to staff if hearing voices or experiencing upsetting thoughts." "Nursing staff will encourage [patient] to identify at least 3 negative effects of substance use and at least 3 reasons to continue taking medications in the community."

A review of RN shift notes revealed that notes mentioned a discussion about medications on 10/29/19 at "02:26" reporting, "This nurse attempted to educate pt. [patient] on importance of taking medications as scheduled, pt. was uninterested." There was no documented evidence that contained information about the name of the medications attempted to be taught, discussed, or duration of sessions. There was no discussion of alternative measures, such as offering the patient written information regarding medications. The other notes were reports of the patient's progress, such as "compliant with medications." There was no documented evidence that the RN discussed the negative effects of substance use with the patient. There was no documented evidence to show that an RN made contact with the patient each shift for at least 5 minutes to implement the above interventions.

2. Patient A2 had the following intervention statements for the psychiatric problem of "[Patient] was seeing things others could not see, believing things others would not, and was being aggressive": "Nursing staff will meet with [patient] for at least 5 minutes each shift when [patient] is awake to encourage [patient] to take [his/her] medications as prescribed and talk with staff if feeling fearful or confused. Nursing staff will orient [patient] to the date and surroundings as needed."

The interventions noted above were routine RN functions, not active treatment interventions. Therefore, the review of the shift notes revealed that there were no treatment notes documented by RNs to show attempts to implement planned interventions to assist the patient in managing presenting psychiatric symptoms. A review of RN shift notes revealed that notes were mostly progress notes. There was one note mentioning patient education, dated 11/4/19 at "02:17" reporting, "Pt was educated about treatment planning, medication compliance, group attendance and self-care during treatment ..." This note contained no details about specific content, the duration of education, or the patient's response.

3. Patient A3 had the following intervention statements for the psychiatric problem of "[Patient] reported fear of losing control with thoughts of harming others and self': "Nursing Staff will meet with [patient] at least 5 minutes each shift when [patient] is awake to encourage [patient] to communicate with others in a calm, respectful manner and not threaten to attempt to harm self or others."

The intervention statements noted above were routine RN functions, not active treatment interventions. Therefore, the review of the shift notes revealed that there were no treatment notes documented by RNs to show attempts to implement planned interventions to assist the patient in managing presenting psychiatric symptoms. A review of RN shift notes revealed that notes were mostly progress notes. There was one note mentioning patient education, dated 11/2/19 at "02:48" reporting, "This nurse educated pt. for 5 minutes about treatment planning, medication compliance, group attendance and self-care during treatment ..." This note contained no details about specific content or the patient's response, such as the level of understanding and participation.

4. Patient A4 had the following intervention statements for the psychiatric problem of "became threatening towards multiple others in the community, was not taking medications": "Nursing Staff will speak with [patient] daily for at least 5 minutes each shift [patient] is awake to encourage [patient] to take medications as prescribed without objection. Nursing will encourage [patient] to identify at least two coping strategies that [patient] can use when angry instead of threatening others."

A review of RN shift notes revealed that notes were mostly progress notes with no documented evidence that reflected what the RN precisely did to assist the patient during the implementation of the interventions above. The only documented evidence that the interventions above were implemented were on 10/30/19 at "19:53" noting, "[S/he] would only list one coping skill which is to work out." On 10/31/19 at "18:55" reporting, "I asked [Patient A4] about reason to continue medications in the community ..." On 11/3/19 at "01:17" reporting, "This nurse educated pt. for 5 minutes about coping strategies [s/he] can use when [s/he] become angry instead of threatening others." This note contained no consistent details about specific content regarding coping skills or the patient's response, such as the level of understanding and participation or duration of sessions. There was no documented evidence to show that an RN made contact with the patient each shift for at least 5 minutes to implement the above interventions.

5. Patient A5 had the following intervention statements for the psychiatric problem of "[Patient A5] hung [him/herself] and had to be cut down by [his/her] sister. [S/he] has not been taking any medication.": "Nursing staff will meet with [Patient A5] each shift while awake for 5-10 minutes ...ed will encourage [him/her] to identify coping skills to manage [his/her] stressors ... identify 3 reasons to avoid street drugs." "Nursing staff will meet with [Patient A5] 10-15 minutes 1 day per week to educate regarding medication compliance to manage mood ... negative impact of street drugs ..."

A review of RN shift notes revealed that there was no documented evidence that contained information about the topic discussed, duration of sessions, or the patient's response to the group interventions such as the note dated 11/1/19 at "13:54," documented by the LPN. However, the RN was identified as the responsible person for the interventions assigned in the MTP. The documentation by the LPN only repeated the intervention regarding medication compliance and noted, "Is taking all medications as ordered to help with mood. Will avoid street drugs." There was no information precisely identifying what medications were discussed or information regarding compliance provided. There was no information regarding the duration of the session or how the patient responded including the level of understanding, level of participation, or behaviors exhibited during the session. There was limited documented by RNs about implementing sessions with the patient for 5-10 minutes to provide information regarding medications or identifying coping skills. A note dated 11/2/19 (no time indicated) reported, "Pt [Patient] accepted education on [his/her] medications" without identifying what medications were taught or the patient's response to this education.

6. Patient A6 had the following intervention statements for the psychiatric problem of "[Patient A6] disclosed suicide ideation with plan and intention. Reported thoughts to jump off a bridge. [S/he] had been hoarding medications with plan to overdose ...": "Nursing staff will meet with [Patient A6] each shift while awake for 5-10 minutes ... will encourage [him/her] to identify 3 coping skills to manage distressing thoughts." "Nursing staff will provide nursing education 2 days per week for 5-10 minutes to educate [Patient A6] about [his/her] medications and benefits of compliance as well as coping skills to manage self-harming thoughts."

A review of RN shift notes revealed that there was no documented evidence that contained information about the topic discussed, duration of sessions, or the patient's response to the group interventions, such as the note dated 11/2/19 at "05:41," reporting "Pt [Patient] accepted education on [his/her] medications." There was no information regarding medications discussed, the duration of the session, or how the patient responded, including the level of understanding, level of participation, or behaviors exhibited during the session. There was only one note dated 11/2/19 at "16:54" regarding coping skills. However, the documentation provided no information given by the RN about coping skills or the duration of the contact with the patient.

7. Patient A7 had the following intervention statements for the psychiatric problem of "[Patient A7] stopped taking medications. [S/he] was not showering often. [S/he] threatened to punch and kill staff ...": "Nursing staff will meet with [Patient A7] 5-10 minutes each shift [s/he] is awake ... encourage [him/her] to talk to staff should [s/he] feel upset or have thoughts to harm others..."

A review of RN shift notes revealed that there was no documented evidence at all that showed the RN attempts to meet with the patient for five to 10-minute sessions each shift. There was no information regarding the RN's attempts to engage the patient, the duration of the session, or how the patient responded.

8. Patient A8 had the following intervention statements for the psychiatric problem of "[Patient A8] took a bottle of pills in a suicide attempt. [S/he] was aggressive toward law enforcement and hospital staff.": "Nursing staff will meet with [Patient A8] at least 5 minutes each shift when [s/he] is awake ... to encourage [him/her] to identify at least 3 benefits of sobriety and at least 3 healthy coping skills he can use to manage depression and suicidal thoughts."

A review of RN shift notes revealed that there was limited documented evidence that reflected what the RN did to assist the patient during the implementation of the interventions above. The note dated 10/30/19 at "06:44," recorded, "I educated patient about medication compliance." However, there was no information about what was taught, or content discussed, or the duration of the contact with the patient. There was no documented evidence to show that an RN made contact with the patient each shift for at least 5 minutes to implement the above interventions.

B. Interviews

1. In an interview on 11/5/19 at 2:20 p.m., Patient A8 was asked about medication education s/he received. Patient A8 reported that s/he had not received any verbal or written information regarding his/her medication education from nurses.

2. In an interview on 11/6/19 at approximately 9:30 a.m., the Director of Nursing did not dispute the findings that there was no documented evidence regarding information taught or provided by registered nurses. She agreed that the duration of contact and the patient's response to interventions were not documented in the medical record.

Based on record review and interview, the facility failed to ensure that active treatment measures were provided for four of eight active sample patients (A2, A4, A7, and A8) 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 to assist with each patient's improvement or treatment goal attainment. Also, there was no consistent documentation in the medical record to show attempts to engage these patients in alternative active treatment measures. Despite inconsistent or lack of regular attendance in groups, Master Treatment Plans (MTP) were not revised to reflect alternative treatment measures to assist patients in making an appropriate recovery. Failure to provide active treatment at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, potentially delaying their improvement or their being discharged without the necessary skills to prevent relapse.

Findings include:

A. Record Review

1. Patient A2

a. Patient A2's Psychiatric Evaluation (PE), dated 10/30/19, reported that the patient was admitted on 10/30/19 with "paranoid and manic and disorganized behavior" with a diagnosis of Bipolar Disorder. Furthermore, the patient was described as "confused, not able to speak clearly even a sentence." Despite these presenting symptoms, group treatment was the sole active treatment interventions assigned in the MTP.

b. Patient A2's MTP (dated 11/1/19) listed the problem as "seeing things others could not see, believing things others would not, and was aggressive." Patients were not assigned groups until three days after admission. Patient A2's interventions for groups were listed as: Brief Supportive Group, Dual Diagnosis Group, Interactive Group, Mood Management Group, Physical Activity Group, Functional Leisure Skills Group, and Social Circle Group.

c. The "Patient Group Attendance Report" for the period 10/30/19-11/4/19 indicated that Patient A2 had attended only two groups.

d. Patient A2's MTP was not revised to address this lack of attendance in groups. There were no new interventions developed that reflected the patient's inability to attend groups and no alternative treatments (individual) were offered.

2. Patient A4

a. Patient A4's Psychiatric Evaluation, dated 10/24/19, reported that the patient was admitted on 10/24/19 with "paranoid and delusional and threatening behavior; aggressive and intrusive, getting into personal space of others. Threatening to kill others and their families." The patient's diagnosis was "Schizoaffective disorder, bipolar type." Despite these presenting symptoms, group treatment was the sole active treatment interventions assigned in the MTP.

b. Patient A4's MTP (dated 10/26/19) listed the problem as "became threatening towards multiple others in the community. Not taking medications." Patients were not assigned groups until three days after admission. Patient A4's interventions for groups were: Interactive Therapy Group, Brief Supportive Therapy Group, Mood Management Group, Physical Activity Group, Leisure Awareness Group, Creative Expressions Group, Relaxation and Coping Skills Group, Functional Leisure Skills Group, Social Circle Group, Recreation Participation Group, Music and Performance Group, and Music Therapy and Relaxation Group.

c. The Patient Group Attendance Report for the period 10/24/19 - 11/4/19 indicated that Patient A2 attended 14 out of 34 offered groups (41%). There were no new interventions developed that reflected the patient's inability to attend most groups and no alternative treatments (individual) were offered.

d. Patient A4's MTP was not revised to address this lack of attendance in groups. There were no new interventions developed that reflected the patient's inability to attend groups and no alternative treatments (individual) were offered.

3. Patient A7

a. Patient A7's Psychiatric Evaluation (PE), dated 8/23/19, reported that the patient was admitted on 8/21/19 with a "long history of mental illness" and a diagnosis of Schizophrenia. The PE noted, "When patient was seen here, [s/he] was selectively cooperative and selectively mute ..." Despite this patient's presenting psychiatric symptoms, group treatment was the primary active treatment interventions assigned in the MTP.

b. Patient A7's MTP, dated 8/22/19, listed the problem as "[Patient A7] stopped taking medications ... [S/he] threatened to punch and kill staff ..." The MTP included the following intervention statements for group treatment:

Therapist: " ... will provide Brief Supportive Group for 60 minutes, 3 days a week, to talk about ... following through with medications to manage [his/her] mental and physical health ..." "Therapist will provide Interactive Group for 60 minutes, 4 days a week to help focus [Patient A7] attention on here and now ..." "Therapist will provide Mood Management Therapy for 60 minutes, 1 day a week to help [Patient A7] learn safe ways to manage and express [his/her] thoughts without destroying property or threatening to harm others."

RT: "Activity Specialist [AS] will provide independent Living Skill 1 day a week for 60 mins [minutes] to help [Patient A7] address lack of activities of daily living ..." "[AS] will provide Functional Leisure Skills 2 days a week for 60 minutes ... to improve ... attention span, and concentration ... to be able to participate in productive leisure activities." " ... will provide "Social Circle 1 day a week for 60 mins to help ... communicate [his/her] wants or needs ..." " ... offer Recreational Participation 6 days a week for 60 mins each session ... to increase ... participation in structured leisure activities."

d. The "Patient Weekly Group Attendance" Sheet reported that the patient attended 30% of the scheduled group during the week of 10/20/19; 46% during the week of 10/27/19; and attended only 42% on 11/3/19. Patient A7's "Group Therapy Progress Notes" from 10/27/19 through 11/4/19 revealed that there was no documented evidence that an alternative intervention was provided when this patient did not attend the assigned group. The "Individual Contact" note, dated 11/4/19, contained no evidence that the therapist provided information or content presented during his/her scheduled groups that were not attended. The "Patient Group Attendance Report" report, except for "Recreation Participation and Music Therapy," that the patient attended 0% of the groups assigned to Activity Specialists. There was no documented evidence that activity specialists provided alternative individual contact with the patient to attempt to engage him/her in active treatment activities for groups s/he refused to attend.

e. The Master Treatment Plan was not revised to reflect alternative active treatment measures to assist the patient in improving presenting symptoms ... The facility submitted 10 MTP Review Forms. However, the only revisions related to the interventions to address psychiatric symptoms were the following similarly worded intervention statements that were mainly to encourage the patient to attend groups, not provide alternative active treatment measures to assist the patient in improving presenting symptoms. On 8/28/19 - 10/29/19, the intervention statement was "Clinical therapist will provide individual contact for 10 to 30 minutes, at least once a week [to assess treatment progress] and to encourage [Patient A7] to attend [his/her] assigned therapy groups and participate in treatment. On 9/11/19, "Music therapy" Group was added. On 10/22/19, the following AS intervention was added. "Activity Specialist will meet with [Patient A7] for 15-30 minutes as tolerated, one day a week to provide Leisure Counseling and offer activities that will encourage him to participate to [his/her] treatment."

4. Patient A8

a. Patient A8's Psychiatric Evaluation (PE), dated 10/21/19, reported the patient was admitted on 10/21/19 with diagnoses of Major depressive disorder, recurrent, severe; Amphetamine type substance use disorder ..." The PE reported, " ...[s/he] had stress and [s/he] cannot quit [his/her] methamphetamine addiction ... [S/he] also had suicidal ideas and tried to commit suicide by ingesting a bottle of pain killer ..."

b. Patient A8's MTP, dated 10/24/19, listed the problem as "[Patient A8] took a bottle of pills in a suicide attempt. [S/he] was aggressive towards law enforcement and hospital staff." [S/he] threatened to punch and kill staff ..." The MTP included the following group intervention statements:

c. Therapist: " ... will provide Brief Supportive Group for 60 minutes, 3 days a week, to encourage to reflect on and discuss [his/her] behaviors that led to [his/her] admission ..." "Therapist will provide Cognitive Group for 4 days a week for 60 minutes to help [Patient A8] learn safe and appropriate ways to manage ... [his/her] depression, negative thoughts ..." "Therapist will provide Dual Diagnosis Group for 2 days a week for 60 minutes each session support goals [sic] for long-term sobriety and learn alternative strategies to deal with life stressors other than substance use."

RT: There were no RT interventions listed.

d. The "Patient Weekly Group Attendance" Sheet indicated that the patient attended 0% of the scheduled group during the week of 10/20/19; 43% during the week of 10/27/19; and attended 0% on 11/3/19. Patient A7's "Group Therapy Progress Notes" from 10/27/19 through 11/4/19 revealed that there was no documented evidence that an alternative intervention was provided when this patient did not attend the assigned group. The "Individual Contact" note, dated 10/31/19 contained no evidence that the therapist provided information or content presented during his/her scheduled groups that were not attended. This note was a report of the patient's progress since admission on 10/21/19 and a discussion about group attendance. The social work note reported the patient stated, "[she] has difficulty hearing in groups but has been trying to follow along with handouts." There was little documented evidence that the patient received active treatment at the level and intensity necessary for hospital treatment.

e. The Master treatment plan was not revised to reflect alternative active treatment measures to assist the patient in improving presenting symptoms ... "Patient A8's MTP was reviewed on 10/31/18. The MTP review reported, "[Patient A8] attended 22% of his/her recreational therapy groups and 29% of clinical therapy groups." However, there were no revisions to address psychiatric symptoms. The revised intervention statement was, "Clinical therapist will provide individual contact for 15 to 30 minutes, at least once a week [to assess treatment progress] and to educate [him/her] to assess symptoms and talk with [him/her] regarding attending group therapies." There were no recreational group interventions added despite the notation in the review about RT group attendance.

f. This patient was discharged on 11/5/19. The "Social Service Note," dated 11/4/19 reported, "Discharge Plan: [Patient A8] "[Patient A8] would like to engaged [sic] in inpatient substance use treatment however is not available for a few months and [s/he] voiced willingness to go to [his/her] mother's home upon discharge until treatment facility become available ..." The note also reported, "[Patient A8] did not attend most of the cognitive groups; however, in brief support group [s/he] attended was able to identify triggers of substance use and feeling [s/he] was not enough ..." The MTP stated, "Therapist will assist [Patient A8] with developing a safety plan [s/he] can utilize to help [him/her] manage current life stressors, depressions, and potential suicidal thoughts prior to discharge." However, there was no description of this safety plan, despite the patient having to wait two or more months before inpatient substance abuse treatment would be available.

B. Interviews

1. During an interview on 11/4/19 at 1:55 p.m., SW1 stated, "I don't do alternatives when patient miss group sessions." SW1 noted, "The team leaders are responsible, and I informed them when patients refuse to attend group sessions.

2. On 11/5/19 at 11:30 a.m., the Interim Director of Nursing stated, "No, we do not do alternative treatment if patients do not attend groups. But we encourage them to attend the groups."

3. On 11/5/19 at 12:30 p.m., the Superintendent concurred that alternative therapies are not offered to patients who do not attend groups.

4. On 11/5/19 at 2:00 p.m., Therapist 2 stated that therapists do not offer alternative therapies for patients who do not attend groups.

5. On 11/5/19 at 2:30 p.m., the Director of Recreational Therapy stated, "No, we do not provide alternatives if patients do not attend groups."

6. During an interview on 11/5/19 at approximately 4:10 p.m., the Director of Social Work confirmed that therapists are not responsible for alternative active treatment measures when patients refuse to attend groups. She confirmed that the team leaders implement individual contacts. She did not dispute that the individual contacts documented failed to reflect that the patients obtained information discussed in missed group treatment sessions.

C. Policy Review

The facility policy titled, "Documentation of Efforts to Motivate Patients to Attend Treatment" (dated 9/30/19) stated, "If a pattern of non-attendance is identified, new interventions will be implemented to encourage attendance or provide alternate forms of engagement and active treatment." The facility was not in compliance with this policy requirement.

Based on record review and interview, social work staff failed to document patients' progress notes. Specifically, for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8), the social work staff failed to document progress notes that contained information to address a patient's progress towards treatment goals, clinical course of treatment, or improvement in identified psychiatric problems. The absence of comprehensive documentation of each patient's progress prevented a chronological picture of pertinent changes in the patient's psychiatric condition or responses to social work interventions related to active treatment.

Findings include:

A. Policy Review

The facility's policy dated "August 5, 2016" and titled "Progress Notes- (IM-4.3)" stated, " ... Progress notes are written in narrative and template in the progress note section of the Patient Care System (PCS) ... Each progress note is entered as an independent note describing the patient's behavior, progress, event, or condition ...." The policy also required that "Events requiring progress notes include (but are not limited to): Patient's current clinical status including symptoms and behaviors requiring hospitalization. Description of patient's clinical course reflecting changes in symptoms and behaviors. Documentation of and the patient's response to education and treatment, including medical issues, medication and progress toward treatment goals." The social work staff failed to comply with these policy requirements.

B. Record review

a. The facility staff was asked to provide copies of all progress and group notes for a period of seven days between 10/27/19 to 11/4/19 for all active sample patients (admission dates in parentheses) - A1 (10/25/19), A2 (10/30/19), A3 (10/30/19) A4 (10/24/19), A5 (10/29/19), A6 (10/30/19), A7 (8/21/19) and A8 (10/21/19). Social work staff documented the patient's progress on a form titled "Group Therapy Progress Note" and "Individual Contact Note." A review of the of Group Therapy Progress Note Form revealed that it contained a section titled "Progress/Plan." There was limited or no evidence of the patient's progress or lack of progress toward treatment goals documented by social work staff in this form. The notes failed to show each patient's clinical course or overall improvement, or lack thereof, in presenting psychiatric symptoms. There were only two individual progress notes submitted, one for patient A7 dated 11/4/19, and one for patient A8 dated 10/31/19. The facility submitted no other progress notes written by social work staff for the active sample patients.

B. Interview

During an interview on 11/6/19 at 10:30 a.m. with the Director of Social Work, the progress notes written by social work staff were discussed. She did not dispute the finding that progress notes contained in the "Group Therapy Progress Note" primarily reported patient behavior during the group sessions.

Based on record review and interview, recreational therapy staff failed to document patients' progress notes. Specifically, for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8), the recreational therapy staff failed to document progress notes that contained information to address a patient's progress towards treatment goals, clinical course of treatment, or improvement in identified psychiatric problems. The absence of comprehensive documentation of each patient's progress prevented a chronological picture of pertinent changes in the patient's psychiatric condition or overall responses to recreational therapy interventions related to active treatment.

Findings include:

A. Policy Review

A review of the facility's policy dated "August 5, 2016" and titled "Progress Notes- (IM-4.3)" revealed that the recreational therapy staff failed to comply with these policy requirements outlined in B128.

B. Record review

a. A review of the medical record for progress notes from 10/27/19 to 11/4/19 revealed that no progress notes were written by recreational therapy staff for active sample patients (admission dates in parentheses) - A1 (10/25/19), A2 (10/30/19), A3 (10/30/19) A4 (10/24/19), A5 (10/29/19), A6 (10/30/19), A7 (8/21/19) and A8 (10/21/19). A review of the Group Therapy Progress notes revealed that there was no section titled "Progress/Plan" to document patient progress. The facility submitted no progress notes written by recreational therapy staff for the active sample patients.

B. Interviews

1. During an interview on 11/5/19 at 2:30 p.m., the Director of Recreational Therapy admitted that recreational therapy staff did not document patient progress. She stated, "The computer blocked this section off the form."

2. During an interview on 11/6/19 at 10:30 a.m. with the Director of Social Work, the progress notes written by recreational therapy staff were discussed. She did not dispute the finding that recreational therapy wrote no progress notes.

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

I. Ensure that Master Treatment Plans (MTP) were comprehensive, specific, and individualized with all the necessary components for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, the MTPs did not include:

A. Behaviorally descriptive strength statements that could be used to formulate individualized treatment goals and interventions. (Refer to B119).

B. Individualized treatment goals stated in measurable, observable, and behavioral terms. (Refer to B121).

C. Specific intervention statements based on presenting psychiatric symptoms and identified treatment goals. (Refer to B122).

II. Provide active treatment measures designed to keep patients actively engaged in treatment at a level and intensity necessary for hospital care. Specifically, four of eight active sample patients (A2, A4, A7, and A8) did not receive the active treatment groups as assigned or any alternative active treatment measures when they did not attend group sessions. Also, a revision of the MTP did not occur despite the lack of participation in the group treatment program. Failure to provide active treatment results in affected patients being hospitalized without all active treatment interventions for recovery, potentially delaying their improvement or resulting in their being discharged without the necessary skills to prevent relapse. (Refer to B125).

III. Develop therapeutic activities assessments for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8, which were completed by a trained Activity Therapist. This failure results in patients not being sufficiently evaluated in order to utilize assessment data to form appropriate treatment plan interventions. Thus, the patients' treatment was not individualized for their specific needs, potentially delaying recovery. (Refer to B157).

Based on record review, policy review and interview, the Interim Director of Nursing failed to:

I. Develop specific individualized nursing interventions for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The nursing interventions were generic, job description modalities which were frequently identical between records. This deficiency resulted in a failure to guide treatment staff to achieve measurable, behavioral outcomes. (Refer to B122)

II. Ensure that registered nurses documented detailed and comprehensive treatment notes for psychiatric interventions in the Master Treatment Plan for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, treatment notes were missing or lacked detailed information to show each patient's response to assigned nursing interventions. This failure hindered the treatment team from determining the patient's response to 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 B124).

Based on record review and staff interviews, the Director of Clinical Services failed to:

I. Ensure that social work interventions were based on the individual needs and problems of the patients for eight of eight sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, several therapists' (social work) interventions were similarly worded, and others were routine social work functions. This deficiency has the potential to result in failure to guide treatment staff in helping the patient to achieve behavioral and measurable outcomes. (Refer to B122).

II. Provide alternative treatment measures for four of eight active sample patients (A2, A4, A7, and A8) who were unable/unwilling to attend the groups assigned to social work staff. Failure to provide active treatment results in affected patients being hospitalized without all active treatment interventions for recovery, potentially delaying their improvement or resulting in their being discharged without the necessary skills to prevent relapse. (Refer to B125).

III. Ensure that medical records contained progress notes written by social work staff. Specifically, for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8), the social work staff failed to document progress notes that contained information to address each patient's progress towards treatment goals, the clinical course of treatment, or improvement in identified psychiatric problems. The absence of comprehensive documentation of each patient's progress prevented a chronological picture of pertinent changes in the patient's psychiatric condition or overall responses to social work interventions related to active treatment. (Refer to B128).

Based on record review and interview, the Director of Recreational Therapy failed to:

I. Develop Recreational Therapy Assessments (dates in parentheses) for eight of eight active sample patients A1 (10/29/19), A2 (10/31/19), A3 (10/30/19), A4 (10/24/19), A5 (10/30/19), A6 (11/1/19), A7 (8/23/19), and A8 (no assessment completed) which were completed by a trained Activity Therapist. This failure resulted in patients not being sufficiently evaluated in order to utilize assessment data to form appropriate treatment plan interventions. Thus, the patients' treatment was not individualized for their specific needs, potentially delaying recovery.

II. Develop individualized interventions for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This deficiency resulted in a failure to guide treatment staff to achieve measurable and behavioral outcomes. (Refer to B122).

III. Provide alternative treatment measures for four of eight active sample patients (A2, A4, A7, and A8) who were unable/unwilling to attend groups. Failure to provide active treatment results in affected patients being hospitalized without all active treatment interventions for recovery, potentially delaying their improvement. (Refer to B125).



A. Record Review

Patients A1, A2, A3, A4, A5, A6, and A7 had "Recreation Therapy Initial Screening" forms signed by "Activity Specialist 1." Patient A8 (admitted on 10/21/19) had no assessment completed as of 11/5/19.

B. Interviews

1. On 11/5/19 at 2:30 p.m., the Director of Recreational Therapy informed the surveyors that the Director did not review or co-sign the Recreation Assessments.

2. On 11/6/19 at 10:50 a.m., the Director of Social Work, who supervised Activity Therapy, confirmed that the "Activity Specialists" did not receive documented education/training in how to develop assessments.