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Based on record review and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were identified on the Master Treatment Plan (MTP) for eight (8) of eight (8) sample patients (A, B, C, D, E, F, G, H). This practice resulted in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings are:

Record Review:

1. Patient A - The treatment plan dated 1/13/14 did not include the name of any individual responsible for specific modalities of treatment. Instead, the treatment plan identified a letter (P, M, N, C, SW, E, RT, D) only as being responsible for each specific treatment modality. A "discipline legend" was printed at the beginning of the treatment plan. It read as follows: "P - Psychiatry; M - Medical; N - Nursing; C - Counseling; SW - Social Work; E - Education, RT - Rec Therapy; D- Dietician". Furthermore, there were no medical or psychiatric modalities identified on the treatment plan.

2. Patient B - The treatment plan dated 2/20/14 did not include the name of any individual responsible for specific modalities of treatment. Instead, the treatment plan identified a letter (P, M, N, C, SW, E, RT, D) only as being responsible for each specific treatment modality. A "discipline legend" was printed at the beginning of the treatment plan. It read as follows: "P - Psychiatry; M - Medical; N - Nursing; C - Counseling; SW - Social Work; E - Education, RT - Rec Therapy; D- Dietician". Furthermore, there were no medical or psychiatric modalities identified on the treatment plan.

3. Patient C - The treatment plan dated 2/20/14 did not include the name of any individual responsible for specific modalities of treatment. Instead, the treatment plan identified a letter (P, M, N, C, SW, E, RT, D) only as being responsible for each specific treatment modality. A "discipline legend" was printed at the beginning of the treatment plan. It read as follows: "P - Psychiatry; M - Medical; N - Nursing; C - Counseling; SW - Social Work; E - Education, RT - Rec Therapy; D- Dietician".

4. Patient D - The treatment plan dated 2/20/14 did not include the name of any individual responsible for specific modalities of treatment. Instead, the treatment plan identified a letter (P, M, N, C, SW, E, RT, D) only as being responsible for each specific treatment modality. A "discipline legend" was printed at the beginning of the treatment plan. It read as follows: "P - Psychiatry; M - Medical; N - Nursing; C - Counseling; SW - Social Work; E - Education, RT - Rec Therapy; D- Dietician".

5. Patient E - The treatment plan dated 2/17/14 did not include the name of any individual responsible for specific modalities of treatment. Instead, the treatment plan identified a letter (P, M, N, C, SW, E, RT, D) only as being responsible for each specific treatment modality. A "discipline legend" was printed at the beginning of the treatment plan. It read as follows: "P - Psychiatry; M - Medical; N - Nursing; C - Counseling; SW - Social Work; E - Education, RT - Rec Therapy; D- Dietician".

6. Patient F - The treatment plan dated 2/14/14 did not include the name of any individual responsible for specific modalities of treatment. Instead, the treatment plan identified a letter (P, M, N, C, SW, E, RT, D) only as being responsible for each specific treatment modality. A "discipline legend" was printed at the beginning of the treatment plan. It read as follows: "P - Psychiatry; M - Medical; N - Nursing; C - Counseling; SW - Social Work; E - Education, RT - Rec Therapy; D- Dietician". Furthermore, there were no medical or psychiatric modalities identified on the treatment plan.

7. Patient G - The treatment plan dated 2/6/14 did not include the name of any individual responsible for specific modalities of treatment. Instead, the treatment plan identified a letter (P, M, N, C, SW, E, RT, D) only as being responsible for each specific treatment modality. A "discipline legend" was printed at the beginning of the treatment plan. It read as follows: "P - Psychiatry; M - Medical; N - Nursing; C - Counseling; SW - Social Work; E - Education, RT - Rec Therapy; D- Dietician".

8. Patient H - The treatment plan dated 2/18/14 did not include the name of any individual responsible for specific modalities of treatment. Instead, the treatment plan identified a letter (P, M, N, C, SW, E, RT, D) only as being responsible for each specific treatment modality. A "discipline legend" was printed at the beginning of the treatment plan. It read as follows: "P - Psychiatry; M - Medical; N - Nursing; C - Counseling; SW - Social Work; E - Education, RT - Rec Therapy; D- Dietician".

Interviews:

In an interview on 02/25/14 at 1:45 p.m., the interim Director of Nursing stated that the facility's treatment plans do not require the full name of the individual accountable for specific interventions.

In an interview on 02/25/14 at 1:00 p.m., the Clinical Director acknowledged that the facility's treatment plans do not require the full name of the individual accountable for specific interventions; and that medical staff are not consistently assigned interventions on the treatment plan.