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Based on facility policy review, medical record review, and staff interviews, the facility staff failed to have a written master treatment plan for 3 of 5 behavioral health patients (Patient #15, Patient #7, and Patient #23) reviewed.

Findings included:

Review on 06/20/2023 of the facility policy titled "Interdisciplinary Patient Centered Care Planning" with a revision date of 07/2020 revealed " ... provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient's progress and determine if any modifications are needed. Each patient's written Treatment Plan must include: *Substantiated diagnosis (es) *Identification of problems to be treated and the specific behavioral manifestations of those problems in the patient *Short-term and long term goals for each active problem, developed with patient input *The specific treatment modalities with individualized patient focus *The responsibilities of each member of the treatment team ... 4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment team plan. Whenever possible, the patient and family/responsible party will be included in the treatment team meeting. The treatment team will complete the MTP (master treatment plan) including: a. Completion of diagnosis, problem list, and patient assets on the Treatment Plan Cover Sheet b. Completion of an individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific patient behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention. 5. The patient/family and/or representative is to sign the treatment plan to indicate their agreement with and participation in development of the plan. A designated staff member is responsible for discussing the treatment plan with the patient and family/representative if they are not present at the treatment team meeting. If the patient refuses to sign or is unwilling to sign, that will be documented. If necessary to do the review with the family member/representative remotely, that will be noted on the form ..."

1. Review of an open medical record on 06/20/2023 revealed Patient #15 was a forty-one-year-old male admitted on 06/15/2023 at 1127 under involuntary commitment (IVC) orders for suicidal ideation (SUI) with threats of a plan to walk into traffic and not taking his medications. The medical record revealed Patient #15 had a history of Schizophrenia (mental illness), substance abuse, and tobacco use. The medical record revealed there was no Master Treatment Plan completed as of 06/20/2023 (five days after admission). The medical record revealed Patient #15 was attending group therapy and taking his medications.

Interview on 06/20/2023 at 1229 with Unit Clinician (UC #1) revealed he had handwritten notes for Patient #15 however did not have a Master Treatment Plan. The Master Treatment Plan is supposed to be completed within 72 hours of admission. Patient #15 was admitted on a Thursday and the facility does not have clinicians on the weekends that evaluate and create the Master Treatment Plans. The clinicians on the weekends only function is to provide programming groups.

Interview on 06/21/2023 at 1340 with Director of Clinical Services (Director #2) revealed he was not aware there was no Master Treatment Plan for Patient #15. Director #2 revealed UC #1 would "handwrite things because he was not familiar with or did not like the computer due to being slow on the computer."



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2. Review of a closed medical record on 06/20/2023 revealed patient #7 a 53-year-old male was involuntarily committed on 03/30/2023 for homicidal and suicidal thoughts, an overdose attempt, and an endorsed plan to harm others. Review of the H&P (history and physical) dated 03/31/2023 at 1200 revealed an admitted diagnosis of bipolar disorder and cocaine and alcohol dependency. Record review revealed no master treatment plan had been completed. Record review of the discharge summary revealed the patient was discharged on 04/07/2023. (8 days later)

An interview on 06/21/2023 at 1230 with the (Unit Clinician) UC #1 revealed the master treatment plan should be completed within 72 hours after admission. The UC #1 stated, "I was overwhelmed and drowning during a certain time period and sometimes it just did not get done. The intent was to go back and write it up, but I just never found the time."

An interview on 06/21/2023 at 1250 with the (Director of Clinical Services) Director #2 revealed "The clinician did not follow the policy. A master treatment plan should be done within 72 hours and then updated after 7 days."



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3. Review of the open medical record for Patient #23 revealed a 27 year old male admitted on 06/12/2023 for Schizoaffective disorder (a disorder that affects a person's ability to think, feel and behave clearly). Review revealed the Master Treatment Plan was completed on 06/22/2023 (11 days after admission).

An interview on 06/21/2023 at 1230 with the (Unit Clinician) UC #1 revealed the master treatment plan should be completed within 72 hours after admission. The UC #1 stated, "I was overwhelmed and drowning during a certain time period and sometimes it just did not get done. "

An interview on 06/21/2023 at 1250 with the (Director of Clinical Services) Director #2 revealed "The clinician did not follow the policy. A master treatment plan should be done within 72 hours and then updated after 7 days."

Based on policy review, medical record review and staff interviews, facility staff failed to define specific target dates for short-term and long-term goals for 1 of 3 sampled patients (Patient #17).

The findings included:

Review on 06/20/2023 of the "Interdisciplinary Patient-Centered Care Planning" policy, with a revision date of 07/2020, revealed "...Policy: It is the policy of (facility name) to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patients' progress and determine if any modifications are needed. ... Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan. ... The treatment team will complete the MTP (Master Treatment Plan) including: ... b. Completion of an individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific patient behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. ... "

Medical record review on 06/20/2023 of Patient #17 revealed a 35 year-old female admitted on 06/13/2023 with bipolar disorder, manic severe with psychosis and chemical dependency. Review of Patient #17's Master Treatment Plan (MTP) revealed it was created on 06/14/2023. The MTP listed two problem areas. The first problem area included a Long-Term goal (LTG): "(Patient #17) will show improvement in overall mood and thought processes aligned with reality while out in the community." There was no defined target date for completion of this goal. There were two Short-Term goals (STG) that included, (Patient #17) will be able to participate in 2 organized/focused activities per day for 48 consecutive hours prior to discharge." and "(Patient #17) will be able to interact with peers/staff appropriately for 48 consecutive hours prior to discharge." Review of the STGs revealed there were no defined target dates for completion of the goals. The second problem area included a LTG: "(Patient #17) will (not) engage in binge drinking or use illegal substances while out in the community." There was no defined target date for completion of this goal. There was one STG that included, (Patient #17) will appropriately demonstrate how to manage negative emotions without using illegal substances by utilizing coping skills for 48 consecutive hours prior to discharge." Review of the STG revealed there was no defined target dates for completion of the goal.

Interview on 06/21/2023 at 1240 with the Director of Clinical Services (Director #2) revealed target dates for LTG and STG should be documented for each goal. Director #2 reviewed Patient #17's MTP and reported he did not see target dates documented. Director #2 stated the target dates should be specified and documented at the time the MTP is developed. Interview revealed the therapy goals did not have identified target dates for completion.

Based on policy review, medical record review and staff interview, facility staff failed to document an update on patient's progress toward goals for 2 of 3 sampled medical record reviewed. (Patient #17 and #23).

The findings included:

Review on 06/20/2023 of the "Interdisciplinary Patient-Centered Care Planning" policy, with a revision date of 07/2020, revealed "...Policy: It is the policy of (facility name) to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patients' progress and determine if any modifications are needed. ... Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan. ... The treatment team will complete the MTP (Master Treatment Plan) including: ... b. Completion of an individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific patient behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. ... Interdisciplinary Treatment Plan Update 1. Treatment Plan Review The treatment team, including the patient/family/representative will complete a review of the treatment plan as indicated, or at a minimum every (7) seven days. Identified problems will be summarized, progress toward goals will be reviewed, new goals and interventions identified, as well as discharge considerations will be updated. A treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient's needs. Review of the treatment plan are documented on the appropriate treatment plan forms in the medical record. ..."

1. Medical record review on 06/20/2023 of Patient #17 revealed a 35 year-old female admitted on 06/13/2023 with bipolar disorder, manic severe with psychosis and chemical dependency. Review of Patient #17's Master Treatment Plan (MTP) revealed it was created on 06/14/2023. Review of the MTP on 06/23/2023 (9 days after the MTP was created) revealed no documented update in Patient #17's MTP of progress toward goals. Review of the "Date Achieved/Discontinued " on the Short-Term Goals was blank on each of the three STG areas. The MTP "UPDATE" two-page form with areas to be completed by nursing, psychiatrist and the unit clinician were blank. There were no signatures (staff or patient), or dates on the form.

Interview on 06/21/2023 at 1240 with the Director of Clinical Services (Director #2) revealed the unit clinician should have documented the patient's progress toward goals. Interview revealed patients' progress toward goals should be documented every seven (7) days. Director #2 stated it had been difficult getting therapists (Unit Clinicians) and the facility was currently down three (3) full time therapists. Interview revealed Patient #17 failed to have documented progress toward goals. Interview revealed the facility's policy was not followed.



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2. Medical record review on 06/23/2023 of Patient #23 revealed a 27 year-old male admitted on 06/12/2023 with schizoaffective disorder. Review of the MTP on 06/23/2023 (11 days after admission) revealed no documented update in Patient #23's MTP of progress toward goals. Review of the "Revised Target Date' and the "Date Achieved/Discontinued " on the Short-Term Goals was blank . There was no patient signature or date on the form.

Interview on 06/21/2023 at 1240 with the Director of Clinical Services (Director #2) revealed the unit clinician should have documented the patient's progress toward goals. Interview revealed patients' progress toward goals should be documented every seven (7) days. Director #2 stated it had been difficult getting therapists (Unit Clinicians) and the facility was currently down three (3) full time therapists. Interview revealed Patient #17 failed to have documented progress toward goals. Interview revealed the facility's policy was not followed.

NC00189396, NC00190033, NC00190581, NC00192629, NC00192676, NC00195752, NC00196769, NC00197366, NC00198102, NC00198501, NC00199829, NC00200234, NC00200595, NC00200606, NC00200840, and NC00201296.