HospitalInspections.org

Based on a review of facility documentation and medical records (MR) and staff interview (EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the Important Message from Medicare at the time of admission and /or before discharge for four of five Medicare records reviewed (MR20, MR21, MR22 and MR23).

Findings include:

A review of the facility policy "Completion of CMS/Medicare Required Documentation" reviewed on December 17, 2015, revealed, "Upon admission, the Crisis Department staff will be responsible to present the 'The Important Message from Medicare About Your Rights' to the patient for signature...Prior to the patient's discharge, at least two days before discharge whenever possible, the caseworker will give the patient another copy of the form as a reminder of his/her rights..."

A review of MR20 and MR22 on December 17, 2015, revealed that the Important Message from Medicare notice was not provided to the patients upon admission and at discharge.

A review of MR21and MR23 on December 17, 2015, revealed that the Important Message from Medicare notice was not provided to the patients upon discharge.

An interview on December 17, 2015, at 12:46 PM with EMP14 confirmed that the Important Message from Medicare notice was not present in the medical record for admission and/or discharge for MR20, MR21, MR22 and MR23.

Based on a review of facility policy and procedures, medical records (MR) and staff interview (EMP), it was determined that the facility failed to have a policy to address prompt notification of a patient's hospital admission to a family member, representative of choice, and physician for nine of nine medical records reviewed (MR1, MR4, MR5, MR6, MR7, MR8, MR9, MR10 and MR11).

Findings include:

Review on December 18, 2015, of the facility's "Family Contact/Session Policy" dated September 25, 2015, revealed "...Procedure: The caseworker obtains the patient's permission to contact the family/significant other by having a confidential release form signed..."

A review of the facility's "Procedure Regarding Contact with Primary Care Physician (PCP)" on December 18, 2015, revealed, "Physician Assistant to obtain the name of the patient's primary care physician...They will also attempt to get a phone number or location so Medical Records Staff can make contact...If the patient refuses to sign a release form for the PCP, this will be documented in the record by witnessing the refusal and documenting it in the chart..."

A review of MR1, MR4, MR5, MR6, MR7, MR8, MR9, MR10 and MR11 on December 18, 2015, revealed no documentation that the patient was asked or that the patient's family/significant other and primary care physician was notified of the patient's admission to the hospital.

An interview on December 18, 2015, at 11:15 AM with EMP14 confirmed that the facility failed to have a policy to address notification of the patient's family/significant other and PCP upon admission to the hospital.

Further interview with EMP6 confirmed that MR1, MR4, MR5, MR6, MR7, MR8, MR9, MR10 and MR11 did not include documentation that the patient was asked or that the patient's family/significant other and PCP was notified upon admission.

Based on a review of facility policy and medical records (MR) and staff interview (EMP), it was determined that the facility failed to document the type of restraints used for two of five medical records reviewed (MR8 and MR9).

Findings include:

A review of facility policy "Seclusion and Restraint Policy and Procedure" dated December 16, 2015, revealed "...Documentation: The registered nurse will initiate the Seclusion/ Restraint Monitoring Record when a patient is placed in seclusion or restraints. The Seclusion/Restraint Monitoring Record will be given to the psychiatric technician assigned to the 1:1 Continuous Observation after being documented with the following information: Detailed description of behavior necessitating use of seclusion or restraints. Patient's trauma history. Ineffective interventions attempted prior to seclusion or restraints..."

A review of MR8 and MR9 on December 17, 2015, revealed no documentation of the type of restraint used for the patient.

An interview with EMP14 on December 17, 2015, confirmed that the type of restraints used for MR8 and MR9 were not documented in the nursing assessment or medical chart and the facility's policy does not address documentation of the type of restraint used for the patient.

Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to document interventions and establish benchmarks for quality indicators to address 30 day readmissions and completion of informed consents.

Findings include:

A review of the facility's "Performance Improvement/Survey Preparedness Minutes" on December 16, 2015, revealed no documentation that interventions or established benchmarks for 30 day readmissions and informed consent completion were addressed during the meetings held from January 22, 2015, to October 21, 2015.

An interview on December 16, 2015, at 11:30 AM with EMP2 confirmed that no interventions or established benchmarks for 30 day readmissions and informed consent completion were documented in the meeting minutes from January 22, 2015, to October 21, 2015.

Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to document the reason for conducting the selected performance improvement projects.

Findings include:

Review of the facility's "Performance Improvement Plan 2015" revealed, "... The Performance Improvement Committee is responsible for coordinating and executing the components of the performance Improvement Plan. ... Delineating authority for departmental monitoring and evaluation activities ... monitors problem resolution ... Communicating information from the monitoring and evaluation activities. ... "

A review on December 16, 2015, of the facility's "Improvement/Survey Preparedness Minutes" dated January 22, 2015, through October 21, 2015, revealed the lack of documentation to indicate the reason for conducting the selected performance improvement projects.

An interview on December 16, 2015, at 2:10 PM with EMP2 confirmed that the meeting minutes dated January 22, 2015, through October 21, 2015, failed to include the reason the quality/performance indicators were selected.

Based on a review of facility policy, medical records (MR) and staff interviews (EMP), it was determined that the facility failed to include interventions related to the medical diagnosis in the patient's treatment care plan for two of two medical records reviewed (MR4 and MR5).

Findings include:

A review of facility's "Multidisciplinary Treatment Plan Policy and Procedure" dated February 28, 2014, revealed, "The multidisciplinary treatment team, in collaboration with the patient, develops and individualized master treatment plan that is based on the patient's assessed needs and strengths. ... Each discipline will give their own interventions tailored to meet the needs of the patient. ..."

A review of MR4 revealed the patient was admitted on November 16, 2015, with medical conditions of diabetes, hypertension and hypercholesterolemia. The multidisciplinary treatment care plan for MR4 failed to include interventions related to the medical diagnosis of the patient.

A review of MR5 revealed the patient was admitted on December 6, 2015, with medical conditions of Asthma and Gastro Esophageal Reflux Disease. The multidisciplinary treatment care plan for MR5 failed to include interventions related to the medical diagnosis of the patient.

An interview on December 17, 2015, at 10:30AM with EMP16 confirmed that the medical conditions were not address in the multidisciplinary treatment care plan for MR4 and MR5. Further interview revealed that only psychological issues were addressed in the treatment care plans and the medical conditions were not addressed in any of the facility's patients' treatment care plans.

Based on a review of facility policy and documentation, and staff interview (EMP), it was determined that the facility failed to complete the medical records within 30 days of discharge.

Findings include:

A review of the facility's "Procedure Manual Medical Records Department" dated December 2013, revealed, "...Complete MCES or CRP Deficiency Sheet indicating missing signature/items in the record. ..." Also reviewed was the "Deficient/Delinquent Charts" which revealed, " ... delinquent charts (at least 30 days incomplete...). ... "

A review of the "Montgomery County Emergency Service Delinquent Medical Record" revealed that in August 2015, 120 of 197 charts were incomplete after 30 days of discharge. Further review revealed thirteen discharge summaries that were not dictated within 30 days of discharge.

Further review of the "Montgomery County Emergency Service Delinquent Medical Record" revealed that in September 2015, 152 of 195 charts were incomplete after 30 days of discharge. Also discovered were thirty seven discharge summaries that were not dictated within 30 days of discharge.

Additionally, the "Montgomery County Emergency Service Delinquent Medical Record" revealed that in October 2015, 121 of 192 charts were incomplete after 30 days of discharge. The review also revealed seventy two discharge summaries that were not dictated within 30 days.

An interview conducted on December 18, 2015, at 12:00 PM with EMP15 confirmed the above findings and that the facility failed to complete charts within 30 days of discharge.

Based on a review of job descriptions, medical records (MR) staff interviews (EMP), it was determined that the facility failed to make adequate provisions for dietary consultations to meets the needs of patients for two of two medical records reviewed (MR1 and MR2).

Findings include:

A review of facility policy "Scope of Dietetic Services" dated August 18, 2015, revealed, "Therapeutic goals include the following: 1. To assess the patient's nutritional status and special dietary needs. 2. To provide dietary education to patients when indicated... "

A review of the dietician job description revealed, "...Nutritional assessments of patients who are screened at nutritional risk and or on a therapeutic diet."

A review of MR1 revealed the patient was admitted on December 11, 2015, and prescribed a therapeutic diet. Further review of MR1 revealed the patient did not have a dietary consultation to meet the needs of the patient.

A review of MR2 revealed the patient was admitted on December 6, 2015, and prescribed a therapeutic diet. Further review of MR2 revealed the patient did not have a dietary consultation to meet the needs of the patient.

An interview conducted on December 17, 2015, at 11:00AM with EMP16 and EMP17 confirmed that MR1 and MR2 were on a therapeutic diet and the medical records failed to include documentation that dietary consultations were provided in order to meet the needs of the patients.

This condition level deficiency was cited during a Life Safety Code survey completed on December 21, 2015. Further details are provided in the Life Safety Code survey report.

Based on a review of job descriptions, personnel files (PF), and staff interviews (EMP), it was determined the facility failed to have a qualified Infection Control Officer (ICO).

Findings include:

A review of the ICO's job description revealed, "...Education and Experience...2. Completion of a basic training program for infection control. 3. Certification in infection control and participation in regional APIC meetings is desired. 4. Ability to develop policies and procedures. 5. Ability to teach and evaluate clinical performance. ..."

A review of EMP18's personnel file revealed verification of ICO training on May 13, 2010, titled "New CMS Infection Control Standards: Ensure compliance & Reimbursement...Format Self Study."

An interview on December 17, 2015, at 2:30 PM with EMP18 confirmed that the Infection Control Officer's last training occurred on May 13, 2010, and it was a self study format.

An interview on December 17, 2015, at 2:35 PM with EMP16 confirmed that the facility failed to ensure the Infection Control Officer maintained qualifications through ongoing education and training.

Based on a review of medical records and staff interview (EMP), it was determined that the facility failed to evaluate the reason for readmissions for patients readmitted within 30 days of discharge (MR13).

Findings include:

A review of MR13 on December 16, 2015, revealed the patient was readmitted to the facility within 30 days of discharge. Further review revealed a lack of documentation to indicate an evaluation regarding the reason for readmission was completed.

An interview on December 16, 2015, at 2:00 PM with EMP2 confirmed that MR13 was not evaluated to determine whether the readmission was due to problems in discharge planning and /or was preventable. Futher interview confirmed that no patients who were readmitted within 30 days of discharge were evaluated to determine if readmission was due to problems in discharge planning.

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

I. Provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (A5, A9, B14, B16, B20, C3, C9, and C21). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Provide comprehensive Master Treatment Plans that reflected appropriate active treatment to be given to patients and provided by the facility staff. Specifically, the facility failed to provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary components to provide active treatment. The MTPs were missing the following components:

A clearly defined inventory of patients' strengths/assets that could be used in treatment planning for seven (7) of eight (8) active patients (A5, A9, B14, B16, B20, C3 and C9) and problem/challenges statements for eight (8) of eight (8) active sample patients (A9. B14, B16, B20, C3 and C9). (Refer to B119)

B. Individualized short-term goals in observable and behavioral terms for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9 and C21). Long-term goals were often vague statements and did not spell out for the staff the specific behaviors the patient was expected to achieve. The short-term goals were frequently not stated in observable, measureable behavioral terms. (Refer to B121)

C. Individualized and specific active treatment interventions for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9 and C21). (Refer to B122)

D. The name of staff persons responsible for the specific aspects of care (interventions) listed on MTPs for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9, and C21). (Refer to B123)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patients ' active treatment needs not being met.

III. Ensure that active treatment interventions listed on the treatment plan and/or unit schedule were documented by registered nurses, social workers, and allied therapy staff to include the patients ' participation or non-participation, specific topics discussed, and the patients' behavior during interventions, and their response to the intervention, including level of participation, understanding, and specific comments for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9, and C21). This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124)

IV. Provide active treatment, including alternative interventions for four (4) of eight (8) active sample patients (A9, B14, C3, and C9) who were either not cognitively capable of participating in treatment at times or were not motivated to attend all groups listed on each unit's activity schedule. The patients regularly and repeatedly did not attend group therapies. These patients spent many hours either wandering the halls or lying on their beds. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals and objectives, potentially delaying their improvement. (Refer to B125I)

V. Ensure that physician orders were written for use of seclusion and/or restraints for five (5) of five (5) non-sample patients (E1, E2, E3, E4, and E5) whose records were reviewed for adherence to facility policy on seclusion/restraints. This failure results in a violation of patients rights to be maintained in the least restrictive environment. (Refer to B125II)

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (A5, A9, B14, B16, B20, C3, C9, and C21). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

1. Patient A5 was admitted 12/1/15. The "Psychosocial Assessment" dated 12/2/15 and 12/3/14 was not completed and the form had the following statement, "Individual unable to complete assessment (attempts must continue throughout hospitalization). After three signatures are obtained document should be made in the progress notes." Only two attempts were documented and as of 12/22/15, the psychosocial assessment and progress notes failed to include detailed factual and historical information about the patient, a social evaluation, conclusions and recommendations based on the social worker's assessments, or a description of the social worker's role in treatment the patient.

2. Patient A9 was admitted 12/4/15. The "Psychosocial Assessment" dated 12/7/15 failed to include a sufficient conclusion of findings regarding discharge barrier and needs. In addition, there was no description of the social worker's role in treatment and discharge planning.

3. Patient B14 was admitted 12/4/15. The "Psychosocial Assessment" dated 12/4/15 and 12/6/15 was not completed and the form had the following statement, "Individual unable to complete assessment (attempts must continue throughout hospitalization). After three signatures are obtained document should be made in the progress notes." Only two attempts were documented and as of 12/22/15, the psychosocial assessment and progress notes failed to include factual and historical social information about the patient, a conclusions regarding barrier and needs for discharge, and recommendations based on the social worker's assessments, or a description of the social worker's role in treatment the patient.

4. Patient B16 was admitted 12/9/15. 2. The "Psychosocial Assessment" dated 12/15/15 failed to include a sufficient conclusion of findings regarding discharge barrier and needs. In addition, there was no description of the social worker's role in treatment and discharge planning.

5. Patient B20 was admitted 10/5/15. The "Psychosocial Assessment" dated 10/5/15 failed to include a sufficient conclusion of findings regarding discharge barrier and needs. In addition, there was no description of the social worker's role in treatment and discharge planning.

6. Patient C3 was admitted 11/5/15. The "Psychosocial Assessment" dated 11/5/15 failed to include a sufficient conclusion of findings regarding discharge barrier and needs. In addition, there was no description of the social worker's role in treatment and discharge planning.

7. Patient C9 was admitted 12/14/15. The "Psychosocial Assessment" dated 12/14/15 failed to include a sufficient conclusion of findings regarding discharge barrier and needs. In addition, there was no description of the social worker's role in treatment and discharge planning.

8. Patient C21 was admitted 12/17/15. The "Psychosocial Assessment" dated 12/18/15 failed to include a sufficient conclusion of findings regarding discharge barrier and needs. In addition, there was no description of the social worker's role in treatment and discharge planning.

B. Interview

During an interview with the Director of Social Work on 12/22/15 at 2:10 p.m., the psychosocial assessments for A5, B14, C3, and C21 were discussed. She did not dispute the findings regarding the lack of sufficient conclusions regarding discharge barriers and needs. She also acknowledged that the Psychosocial Assessments did not contain a description of the social work role in treatment and discharge planning.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) clearly defined inventory of patients' strengths/assets and problem statements written in behavioral and descriptive term. Specifically, the MTPs included a short list of vague patient traits or external support resources labeled as "strengths," which results in poorly defined goals and interventions for seven (7) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, and C9). In addition, many of the stated problems on the treatment plans included diagnoses and/or generalized lists of symptoms instead of specific individualized and descriptive clinical symptoms/behaviors for six (6) of eight (8) active sample patients (A9, B14, B16, B20, C3, and C21). These failures can adversely affect clinical decision-making in formulating goal and intervention statements and results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Record Review

1. Active sample patient A5's MTP dated 12/3/15 and update 12/9/15 had the following asset/strength identified.

The patient's asset/strength was: "Supportive [boy/girlfriend]."

There was no inventory of strengths that would help in treatment planning such as previous helpful experiences during hospitalization, education level, talent, skills, etc. The asset listed was vague and failed to identify how the supportive friend would be helpful in treating the patient.

2. Active sample patient A9's MTP dated 12/7/15 had the following psychiatric problem statement (called challenges by the facility) and patient asset/strength identified:

The problem statement was: "Unable to care for self. Evidenced/Triggered by: patient is disorganized and disrobing in the crisis center." The patient's asset/strength was: "Everything."

The problem was a general behavior and failed to describe how "disorganized" was precisely manifested by the patient. The asset was a quote made by the patient. There was no inventory of assets and no information documented showing that clinical staff attempted to identify and obtain patient assets that could be used in developing treatment goals and providing treatment.

3. Active sample patient B14's MTP dated 12/4/15 and update 12/11/15 had the following psychiatric problems (called challenges by the facility) and patient asset/strength identified:

The problem statement was: "Unable to care for self. Evidenced/Triggered by: malodorous, disshelved [sic], disorganized thought." The patient's asset/strength inventory listed one strength: "Cook."

The problem statements were generalized and failed to include a description of disorganized thoughts. There was no inventory of strengths that would help in treatment planning such as previous helpful experiences during hospitalization, education level, talent, skills, etc. The asset was vague and not descriptive of how cooking would be a skill that would helpful in treatment planning and treatment.

4. Active sample patient B16's MTP dated 12/11/15 and update 12/18/15 had the following psychiatric problems (called challenges by the facility) and patient asset/strength identified:

The problem statements listed were: "Disorganized behavior. Evidenced/Triggered by: pt. [patient] assaulted by boy/girlfriend and making illogical statements." "Alcohol abuse: Evidenced/Triggered by: [Patient's name] reports that [s/he] recently had four (4) cans of beer and [s/he] was 'manipulated by [him/her] to drink." The patient's asset/strength was: "Able to verbalize needs."

The patient's problem statement described recent alcohol use but failed to provide a description of the abuse and how it influenced the patient's need for hospitalization. There was no behavior description of "illogical statements." The asset was vague and not descriptive of how the strength would be helpful in treatment planning and providing treatment such as being able to verbalize problems and feelings in individual and group sessions.

5. Active sample patient B20's MTP dated 10/7/15 and last updated 12/17/15 had the following psychiatric problem statement (called challenges by the facility) and patient assets/strengths identified:

The problem statements included: "impulsivity. Evidenced/Triggered by: behavior described in petition." The patient's asset/strength inventory included were: "Multiple OP [Out Patient] supports, cooperative."

The problem was a diagnostic term with no behavioral description of impulsivity or other presenting symptoms. The assets listed were vague and not personal strengths that would help in treatment planning such as education level, talent, skills, etc.

6. Active sample patient C3's MTP dated 12/16/15 included the following psychiatric problems (called challenges by the facility) and patient assets/strengths identified:

The psychiatric problem statements were: "threatening others. Evidenced/Triggered by: pt. [patient] admits to having thoughts if harming others." "Paranoid Delusion. Evidenced/Triggered by: Per record of events PTA [Prior To Admission] and current presentation." The patient's asset/strengths included were: "Connected with outpatient." "I love God." "I love life." "I would like to have a [boy/girlfriend] and be independent." "I love animals."

The problem statements were diagnostic terms with no behavior descriptions reflecting how precisely the patient manifested the behaviors. The assets listed were not personal strengths that would help in treatment planning such as education level, talent, skills, etc.

7. Active sample patient C9's MTP dated 12/15/15 had the following patient asset/strength identified:

The patient's asset/strength was: "family support system."

There was no inventory of strengths that would help in treatment planning such as previous helpful experiences during hospitalization, education level, talent, skills, etc.
The asset was vague and not descriptive of family support such as family visiting patient and/or willing to accept in their home.

8. Active sample patient C21's MTP dated 12/18/15 had the following psychiatric problems (called challenges by the facility) identified:

The problem statements were: "Suicidal. Evidenced/Triggered by: suicidal statements prior to admission. Notes: 'no, that's just babbling cause I was drunk. I am not suicidal." "Depression and Anxiety. Evidenced/Triggered by: [Patient's name] report [This was the only information provided.]

The problem statements included diagnostic terms and failed to describe how the patient precisely manifested these behaviors such as the statement made regarding suicide and behavioral descriptions of depression and anxiety.

B. Policy Review

The facility's policy titled "Multidisciplinary Treatment Plan Policy and Procedure," stated, "Challenges - Include mental health, co-occurring and medical challenges. Challenges should identify the specific reason the patient is requiring inpatient hospitalization and what specific clinical issues are being addressed during treatment. There can be more than one challenge, but a challenge should not be a diagnosis..." The facility failed to follow its policy of not including a diagnosis as a challenge/problem.

The policy also stated, "Strengths - Related to treatment, education and discharge planning. What personal qualities will help the patient achieve his/her treatment goals..." The facility failed to follow its own policy regarding identifying strengths that would help with patient accomplish treatment goals.

C. Interviews

1. In an interview on 12/22/15 at 1:05 p.m., the lack of personal strengths on the Master Treatment plans was discussed with the Medical Director. She stated that they interpreted the standard differently thus considered assets to things that the patient possessed.

2. In an interview on 12/21/15 at 2:30 p.m. with the Director of Quality Improvement, patient assets and problem/challenge statements were discussed. He acknowledged that some of the strengths were not personal attributes of the patient. He agreed that many of problem statements did not include behavioral descriptions of the patient's symptom. He reported that they previously did this but another regulatory agency had asked them to not be as descriptive.

Based on record review and interview, the facility failed to provide Master Treatment plans that consistently identified patient short-term and long-term goals related to their identified problem(s). Long-term goals were often vague statements and did not spell out for the staff the specific behaviors the patient was expected to achieve. The short-term goals were frequently not stated in observable and measureable behavioral terms for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9 and C21). These failures hinder the ability of the treatment team to measure changes in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to patient stays beyond the resolution of the behaviors requiring admission.

Findings include:

A. Record Review

1. Facility policy (no number), dated 12/18/15, titled "Multidisciplinary Treatment Plan Policy and Procedure" stated: "Goals - Brief clinical statement that addresses a specific challenge. A goal summarizes what the patient will achieve during hospitalization. A goal should be directed at learning more and more functional methods of coping with the challenges. Objectives - specific steps necessary to achieve the desired goal. These need to be written in behavioral terms that are specific and measureable to evaluate each patient's progress and in language the patient can understand." In this facility the "goal" was considered the long-term goal and the "objective" the short-term goal.

2. Active sample patient A5, MTP dated 12/9/15 had as a problem: "Disorganized thoughts. Evidenced/triggered by [name of patient] speaks of telepathy and believes that people are evil who put him/her into the hospital." The goal was "to have more organized thoughts." The objective was [name of patient] will review clinical data on schizoaffective disorder. The goal was vague and not written in the specific behavior to be achieved. The goal was also non-specific and made it difficult for staff to know what to observe to determine goal attainment. The objective was very broad and did not describe the expected behavioral outcome for the patient.

3. Active sample patient A9, MTP dated 12/7/15, had as a problem: "Unable to care for self. Evidenced/triggered by: patient is disorganized and disrobing in the crisis center." The goal was: "Patient will be reality based." The objective was "patient will identify three (3) supports to help him/her stay reality based." The goal was vague, did not spell out specific behaviors to be achieved, and did not relate to the problem. The objective was also vague and difficult to measure in that the type of support and behavioral outcome were not defined.

4. Active sample patient B14, MTP dated 12/11/15, had as a problem: "Unable to care for self. Evidenced /triggered by: malodors, disheveled, disorganized thoughts." The goal was "able to provide basic needs." One objective was: "[Name of patient] will have 5 minute reality based conversations daily." The goal was vague and did not relate to the problem. "Disorganized thoughts" was not spelled out. The objective was not observable or measureable as stated. Therefore, it would be difficult for staff to know what to observe to determine whether the patient had accomplished the objective.

5. Active sample patient B16, MTP dated 12/18/15, had as a problem: "Disorganized behavior. Evidenced/triggered by: pt. assaulted boyfriend and making illogical statements." The goal was "[name of patient] to engage in focused conversations." The objective was "[name of patient] to have 5 minute reality based conversation with treatment team member daily." The goal did not relate specifically to the problems. Nor did it spell out what was meant by "focused conversation". The objective was not observable or measureable as stated. "Reality based conversation" was not defined.

6. Active sample patient B20, MTP dated 12/17/15, had as a problem: "Impulsivity. Evidenced/triggered by: behavior described in petition." The goal was "patient will desist from elopement behavior." The objective was: "Patient will work with inpatient team on developing alternative ways of dealing with his/her anger." The goal did not relate to the problem in that the specific behaviors of "impulsivity" by the patient was not described. The objective did not describe observable, measureable behavioral symptoms of anger. Nor did it define specific outcome behaviors to be achieved by the patient.

7. Active sample patient C3, MTP dated 12/16/15, had as a problem: "Threatening others. Evidenced/triggered by: patient admits to having thoughts of harming others." The goal was "patient to be free of thoughts of harming others." The objective was: "Patient will identify three (3) supports to utilize in times of increased stress." The goal was vague and not descriptive of specific behaviors to be achieved. The objective failed to include the specific supports or expected behaviors to be reached.

8. Active sample patient C9, MTP dated 12/15/15, had as a problem: "Thoughts disorder. Evidenced/triggered by: pt. [patient] believes people are watching or spying on him/her." The goal was "improve ability to see world as others do." The objective was "be free of false beliefs, report feeling comfortable spending time with others." The goal was vague and not specifically related to the identified problem. The objective was not observable and measureable behaviors to be achieved.

9. Active sample patient C21, MTP dated 12/18/15, had as a problem: "Suicidal. Evidenced/triggered by: suicidal statement prior to admission." Goal: "[Name of patient] to discuss stressor that lead to behavior prior to admission." Objective was "[name of patient] to verbalize stressor that lead to his/her thoughts of self-harm." The goal was vague in that it did not identify the patient's stressors, nor the specific behavior they caused. The objective was difficult to measure in that the specific suicidal behaviors of the patient, i.e. cutting wrist, jumping in front of a car, were not identified.

B. Interview

In an interview on 12/21/15 at 1:11 p.m. with PhD. #1, he was asked to identify the long-term and short-term goals on the Master Treatment plans (MTPs). He at first stated he was unable to do this. He stated he had never been asked to distinguish between the two. PhD. #1 then stated that the long-term goals were the "goals" on the MTP and the objectives were the short-term goals on the treatment plans. He did not dispute the fact that the goals were often vague and not related to the identified problem and that the objectives were not consistently stated in observable and measureable behaviors.

Based on record review and interview, the facility failed to develop individualized Master Treatment Plans (MTPs) that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9 and C21). Specifically, MTPs failed to include a focus of treatment based on each patient's presenting symptoms and to consistently identify the method of delivery for each intervention. These deficiencies potentially result in staff being unable to provide consistent and focused active treatment.

Findings include:

A. Record Review

1. Active sample patient A5's MTP dated 12/315 and update 12/9/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Unable to care for self. Evidenced/Triggered by: not taking his blood pressure or diabetic meds [medications], not sleeping."

Psychiatrist Intervention: "Medication Management"

Allied Therapy: "Group Therapy"

Treatment Team: "Patient education"

Problem 2: "Nonadherence to medication/tx [treatment]. Evidenced/Triggered by: ...refusing oral medication and remains withdrawn to room, is suspicious and RIS [responding to internal stimuli]..."

Medical Intervention: "Educate [Patient's name] about the benefits of medication to stabilize [his/her] psychotic symptoms..."

Treatment Team: "Encourage [Patient's name] to be an active participant with treatment."

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements regarding medication management, medication education, and patient education did not include whether these interventions would be delivered in individual or group sessions. The intervention statements regarding encouraging the patient was generic and non-specific and would be done by discipline staff for any patient regardless of the patient's presenting symptoms.

2. Active sample patient A9's MTP dated 12/7/15 had the following interventions for the identified psychiatric problem (called challenges by the facility):

Problem 1: "Unable to care for self. Evidenced/Triggered by: patient is disorganized and disrobing in the crisis center."

Psychiatrist Intervention: "Medication Management"

Allied Therapy: "Group Therapy"

Treatment Team: "Patient education"

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements regarding medication management and patient education did not include whether the interventions would be delivered in individual or group sessions.

3. Active sample patient B14's MTP dated 12/11/15 had the following interventions for the identified psychiatric problem (called challenges by the facility):

Problem 1: "Unable to care for self. Evidenced/Triggered by: malodorous, disshelved, disorganized thought."

Psychiatrist Intervention: "Individual counseling"

Nursing: "Monitor ADL's"

Treatment Team: "Individual counseling"

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. These interventions also did not include a delivery method. The intervention statement to be implemented by nursing staff was actually a task not a treatment intervention reflecting what nursing would be to assist the patient to improve his/her presenting problems.

4. Active sample patient B16's MTP dated 12/11/15 and update 12/18/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Disorganized behavior. Evidenced/Triggered by: pt. [patient] assaulted by boy/girlfriend and making illogical statements."

Treatment Team Intervention: "Individual Counseling"

Medical Staff Intervention: "Medication education"

Problem 2: "Alcohol abuse. Evidenced/Triggered by: [Patient's name] reports that she recently had 4 cans of beer and [s/he] was 'manipulated by [him/her] to drink'."

Allied Therapy Intervention: "COD [Co-Occurring Disorder] group therapy"

Treatment Team: "Educate on the negative effects of alcohol use."

Excluding the intervention regarding alcohol use, none of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. Additionally, excluding the intervention assigned to allied therapy, the intervention statements also did not include whether the interventions would be delivered in individual or group sessions.

5. Active sample patient B20's MTP dated 10/7/15 and last updated 12/17/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Impulsivity. Evidenced/Triggered by: behavior described in petition."

Psychiatry: "Individual Counseling"

Problem 2: "Impulsive behaviors leading to dangerous situations (i.e. getting angry and running into traffic)."

Treatment Team Intervention: "Monitor for safety, re-direct as needed." "Offer support and education on the dangerousness of running into traffic/acting out when upset." "Encourage active group participation, offer 1:1 support as needed." "Offer support and provide education on the benefits of additional support."

Social Services Intervention: "Contact family and OP [Outpatient] supports, arrange meeting, facilitate meeting." "Research appropriate locations, coordinate with family and OP [Outpatient] supports; arrange discharge when appropriate."

Problem 3: "Maintaining safety on the unit. Evidenced/Triggered by: [Patient's name] running in the hallway, and tripping/falling."

Treatment Team Intervention: "Reinforce the dangers of running on the unit. Encourage [Patient's name] to wear sneakers, and to walk. Redirect as needed."

Problem 4: Maintaining in the community. Evidenced/Triggered by: Frequent hospitalization and police intervention.

Treatment Team Intervention: "Encourage active group participation." "Assist in identifying ways to stay safe."

Social Services Intervention: "Assist in identifying resources."

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements also did not include whether the intervention would be delivered in individual or group sessions. The intervention statements regarding monitoring and redirecting were discipline tasks not treatment interventions to assist the patient to make improvements in the presenting symptoms.

6. Active sample patient C3's MTP dated 12/16/15 included the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "threatening others. Evidenced/Triggered by: pt. [patient] admits to having thoughts of harming others."

Psychiatrist Intervention: "Medication Management"

Allied Therapy: "Group Therapy"

Treatment Team Intervention: "Patient education" "Meet with [Patient] daily to discuss stressors and the importance of medication compliance."

Social Services: "Continue to attempt to engage [Patient's name] in treatment related discussion."

Problem 2: "Paranoid Delusions. Evidenced/Triggered by: Per record of events PTA [Prior to admission] and current presentation."

Medical Staff/Psychiatrist: "Medication education and Management" "Educate and prescribe medications that [s/he] will be willing to take on a long term basis."

Social Services: "Connect without patient support system, coordinate meeting with staff and treatment team." "Patient education. Disposition planning." "Continue to coordinate treatment plans and meetings with CHS [Creative Health Services] LTRS [Long Term Residential Services] staff and [his/her] PO [probation officer] prior to discharge."

Allied Therapy: "Group therapy"

Treatment Team: "Monitor status, redirecting as necessary."

Medical Staff Intervention: "Medication education"

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements also did not include whether the intervention would be delivered in individual or group sessions. The intervention statements regarding monitoring and redirecting were discipline tasks not treatment interventions to assist the patient to make improvements in the presenting symptoms.

7. Active sample patient C9's MTP dated 12/15/15 had the following interventions for the identified problem (called challenges by the facility):

Problem 1: "Thought Disorder. Evidenced/Triggered by: Per 302, pt. [patient] believes people are watching or spying on [him/her]."

Psychiatrist/Medical Intervention: "Medication Review" "Patient Education"

Treatment Team Intervention: "Individual Counseling"

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements also did not include whether the intervention would be delivered in individual or group sessions.

8. Active sample patient C21's MTP dated 12/18/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Suicidal. Evidenced/Triggered by: suicidal statements prior to admission. Notes: 'no, that's just babbling cause I was drunk. I am not suicidal."

Treatment Team Intervention: "Individual Counseling"

Problem 2: "Substance use. Evidenced/Triggered by: [Patient's name] report of recent alcohol binge and cocaine use. UDS [Urine Drug Screen] + for cocaine, benzodiazepine and barbituates [sic]."

Allied Therapy Intervention: "Group therapy"

Social Services: "Patient Education."

Medical Staff: "Monitor for signs and symptoms of withdrawal. Encourage utilization of Serax detox taper."

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statement regarding patient education also did not include whether the intervention would be delivered in individual or group sessions. The intervention statements for medical staff were generic and routine clinical tasks rather than specific treatment interventions to assist the patient to improve.

Problem 3: "Depression and Anxiety. Evidenced/Triggered by: [Patient's name] report"

Medical Staff: "Medication management"

Treatment Team: "Patient education and support"

Allied Therapy: "Group therapy"

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statement regarding patient education also did not include whether the intervention would be delivered in individual or group sessions. The intervention statements for medical staff were generic and routine tasks rather than specific treatment interventions to assist the patient to improve.

B. Policy Review

The facility's policy titled "Multidisciplinary Treatment Plan Policy and Procedure," stated, "Intervention/Method - Briefly describes what will be done to help the patient achieve the identified goals and objectives". The facility policy failed to provide guidance to staff regarding CSM requirements stipulating individualized and specific modalities with a focus of treatment for each patient.

C. Interviews

1. In an interview on 12/21/15 at 1:11 p.m. with PhD. #1, the MTPs for the active sample patients were discussed. He acknowledged that the intervention statement did not include a focus of treatment. However, he explained that the objectives were considered to be the focus of the treatment interventions.

2. In an interview on 12/22/15 at 4:15 p.m. with RN #2, the MTPs for Patients A5, B14, B16, and B20 were discussed. RN #2 agreed some nursing interventions such as monitoring, redirecting, and encouraging patients were nursing tasks instead of treatment interventions to assist the patient to improve presenting symptoms.

Based on record review and interview, the facility failed to ensure that the name of staff persons responsible for the specific aspects of care (interventions) were listed on the multidisciplinary treatment plans (MTPs) for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9, and C21). This practice results in the facility's inability to clearly monitor staff accountability for seeing that specific treatment modalities are carried out.

Findings include:

A. Record Review

1. Facility policy (no number), dated 12/8/15, titled "Multidisciplinary Treatment Plan Policy and Procedure", stated: "The treatment team is multidisciplinary and includes assigned clinical staff (attending psychiatrist/nurse practitioner; psychologist, if applicable; nurse; caseworker and allied therapist)"---"team present for development of treatment plan - list of staff members involved in the treatment plan meeting/ development, staff entering data - the staff member who served as scribe during the development of the treatment plan." The facility's policy failed to include the requirement to include the name of the staff responsible for ensuring that the intervention is provided.

2. The following MTPs (dates of treatment plans in parenthesis) did not include a name of staff to be held accountable for seeing that interventions on the plans were carried out: A5 (12/9/15), A9 (12/7/15), B14 (12/11/15), B16 (12/8/15), B20 (12/17/15), C3 (12/16/15), C9 (12/15/15) and C21 (12/18/15).

B. Interview

In an interview on 12/22/15 at 2:00 p.m., the lack of specific names of staff persons to be held accountable for seeing that treatment interventions were carried out on the Master Treatment Plans was discussed with the Nursing Director. She did not dispute the problem.

Based on record review and interview, the facility failed to ensure that active treatment interventions listed on the treatment plan and/or unit schedule were documented in the medical record to include the patients' attendance or non-attendance, specific topics discussed, and the patients' behavior during interventions, and their response to the intervention, including level of participation, understanding, and specific comments. This included interventions assigned to registered nurses, social workers, and allied therapy staff as a member of the "Treatment Team" for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9 and C21). This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

The master treatment plans for the following patients were reviewed (dates of plans in parentheses): A5 (12/9/15); A9 (12/7/15); B14 (12/11/15); B16 (12/18/15); B20 (12/17/15); C3 (12/16/15); C9 (12/15/15); and C21 (12/18/15). This review revealed that registered nurse and social services interventions were primarily included in those assigned to the entire treatment team.

1. Patient A5, A9, B14, C3 and C21 all had following treatment interventions regarding "Patient education for an array of issues identified in treatment goals assigned to the treatment team."

a. Patient A5: "identify 3 supports to help care for [him/herself]."

b. Patient A9: "...identify 3 supports to help [him/her] stay reality based."

c. Patient B14: "...verbalize 1 benefit of medication compliance";

d. Patient C3: "identify 3 supports to utilize in times of increased stressed"; "discuss...the importance of medication compliance."

e. Patient C21: "...identify at least 3 triggers to symptoms of depression and anxiety"; "...identify at least 2 healthy coping skills."

A review of registered nurses, social work and allied therapy staff treatment notes for the period of 12/13/15 through 12/22/15 revealed that there were no treatment notes documentation by registered nurses to show that they met with these patients to discuss and provide information about the above treatment issues with a report of how the patient responded to the interventions. There were also only a few treatment notes by social workers that actually mentioned the issues identified in the treatment objectives when meeting with patients. The allied therapy staff documented attendance and non-attendance in groups, however there were usually no mention that the issues identified in the treatment objectives were addressed in group sessions. There was no correlation between the interventions identified on the treatment plan and those provided on the unit.

2. Patient B14, B16, C3, and C21 all had following treatment interventions regarding "Individual Counseling." All of these MTP included the following identical or similarly worded objectives: "[Patient ' s name] will have 5 minutes reality-based conversations daily."

A review of registered nurses, social work and allied therapy staff progress notes for the period of 12/13/15 through 12/22/15 revealed that there were no treatment notes documentation by registered nurses to show that they met with these patients to discuss reality oriented conversations and how the patient responded to the interventions.

3. A review of the medical record for the period 12/13/15 through 12/22/15 revealed the following interventions assigned to be implemented by the treatment team that failed to include treatment notes by the registered nurse that showed that the intervention was held or not held. Additionally, there no documentation to show the topic(s) discussed, information provided and how the patient responded to the intervention(s).

a. Patient A5: "...review information on [his/her] illness to gain insight into [his/her] symptoms."

b. Patient B16: "Educate on the negative effects of alcohol use."

c. Patient B20: "...education on the dangerousness of running into traffic/acting out when upset." Treatment notes regarding this intervention was only found in social services notes. "...provide education on the benefits of additional supports."

d. Patient C3: "Meet with [Patient's name] daily to discuss stressors and the importance of medication compliance."


B. Interviews

1. In an interview on 12/21/15 at 11:45 a.m., the interventions on Patient B14's and B16's MTPs were discussed with RN #3. She agreed that there was no treatment notes documented to show that the RN met with the patient to discuss medication compliance with Patient B14 and to discuss the negative effects of alcohol use with Patient B16.

2. In an interview on 12/22/15 at 1:35 p.m., with the Director of Nursing, the MTPs for the active sample patients were discussed. She admitted that registered nurses were not writing treatment notes to address patient education interventions identified on treatment plans. She reported that the registered nurses provide education during medication administration but agreed that RNs do not document treatment notes reflecting topics or medication discussed and how the patient responded to the patient education.

3. In an interview on 12/23/15 at 9:30 a.m., with RN #4, the MTP for Patient A9 was discussed. RN #4 admitted that registered nurses did not document treatment notes related to the "Patient Education" intervention identified on the treatment plan.

Based on record review and interview, the facility failed to provide active treatment, including alternative interventions for four (4) of eight (8) active sample patients (A9, B14, C3, and C9) who were either not cognitively capable of participating in treatment at times or were not motivated to attend all groups listed on each unit's activity schedule. The patients regularly and repeatedly did not attend group therapies. These patients spent many hours either wandering the halls or lying on their beds. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals and objectives, potentially delaying their improvement.

Findings include:

A. Patient A9

1. Patient A9 was admitted on 12/11/15. The Psychiatric Evaluation, dated 12/4/15, documented that "patient is a 51year old AAF [African American female] presenting here on 302 [involuntary commitment of 5 days]. Patient is currently disorganized and psychomotor agitated. Patient is pacing back & [and] forth after s/he disrobed in the crisis center. Patient is uncooperative with the interview. Patient is unable to care for self in current state."

2. The only modalities identified on patient A9's Master Treatment plan (MTP), dated 12/7/15, were general ones such as "medication management, group therapy, patient education, medication education." There was no mention of alternatives to include on the MTP to substitute for the patient not going to assigned group.

3. The patient was observed in [his/her] bed on 12/21/15 at 11:40a.m. with eyes closed. The group "mindfulness", which had started at 11:00a.m., was being conducted on North Hall.

4. When asked if patient A9 was supposed to be in that group, MHT #2 stated "Yes, but s/he is sleeping." When asked if patient A9 had been out of his/her room today, MHT #2 stated "S/he's been out to eat. S/he does come out of room to mingle and walk around, but s/he has not been to any groups yet today."

5. A review of the patient's "Continuous Observation Record" for the following days stated:
12/13/15 - 9 a.m. - "Polynesian room dancing, pacing unit, yelling at staff about bible."

10 a.m. - "pt. rested in bed entire hour."

11 a.m. - "Pt. rested in bed."

12 p.m. - "Pt. ate lunch, rested in bed."

2 p.m. - "Pt. sleeping awake and took shower."

3 p.m. - "Pt. went to room and rested this hour."

4 p.m. - "Pt. appeared to sleep for first half of the hour, awoke and used BR [bathroom], then paced hall."

5 p.m. - "Pt. paced watch TV, used BR."

12/14/15 - 8 a.m. - "Pt. ate breakfast then rested in his/her room."
9 a.m. - "Pt. slept."

10 a.m. - "Pt. laying quietly in bed."

11 a.m. - "Pt. rested in bed for most of the hour."

12 p.m. - "Pt. relaxed, then consumed lunch."

1 p.m. - "Pt. slept first ½ of hour, then sat in activities."

3 p.m. - "Pt. walked around the unit and relaxed in room."

4 p.m. - "Pt. laid in bed, sat in Zone 1 and drank juice, listened to music & watched TV."

12/15/15 - 7 a.m. - "Pt. used bathroom, then sat in activities room."

8 a.m. - "Pt. slept."

9 a.m. - "Pt. ate quietly with peers."

10 a.m. - "Pt. laying quietly in bed."

11 a.m. - "Pt. slept & used bathroom."

12 p.m. - "Pt. ate lunch then rested in bed."

2 p.m. - "Pt. slept most of hour, got up and socialized with peers in Zone 1."

3 p.m. - "Pt. rested in his/her room and paced the unit this hour."

4 p.m. - "Pt. rested in room this hour."

6. The "Nursing Shift Assessment and Flow Sheet" dated 12/13/15 at 2:30 p.m. stated: "Pt. spent most of the day in his/her room. S/he did not participate in groups or activities." Nursing Note, dated 12/14/15 at 11 a.m., stated "Pt. remains withdrawn to his/herself, and is very brief when engaging in a reality based conversation. Encouraged [name of patient] to attend and participate in groups and activities to gain insight on developing positive coping strategies for dealing with anger."

Nursing note, dated 12/15/15 at 9:15 a.m., stated "Pt. remains withdrawn to self. However when agitated [name of patient] can become hostile."

Nursing note, dated 12/20/15 at 9:00 a.m., stated "Pt. remains [eligible word], however spends a great deal of time in his/ her room."

7. In an interview on 12/22/15 at 11:00 a.m., the lack of attendance of patient A9 in attending groups was discussed with MD #1. She stated, "[name of patient] is a problem. We know this patient very well. When s/he comes in, we don't bother him/her because s/he can get aggressive. S/he does not want to take his/her meds [medication] so we allow him/her to stay in room and sleep until his/her meds start to work."

B. Active sample patient B14

1. Patient B14 was admitted on 12/4/15. The Psychiatric Evaluation, dated 12/3/15, documented, "51yr [year] old [gender] brought in 302 by family [child] reporting swinging knife in threatening manner, talking to self, not bathing..."

2. The intervention statements identified on patient A9's Master Treatment plan (MTP), dated 12/7/15, were general ones such as "Individual Counseling" assigned to psychiatry and the treatment team, "Monitor ADL" assigned to nursing staff, and "Patient Education" assigned to the entire treatment team. A review of the medical record for the period 12/13/15 through 12/22/15 revealed no treatment notes by registered nurses and allied therapy staff that mentioned the issues identified in objectives were addressed with the patient. In addition, there was no mention of alternatives included on the MTP to substitute for the patient not participating in assigned intervention.

3. A review of the facility's schedule of groups conducted by the allied therapy staff listed the following groups scheduled to be held throughout the day: "Co-Occurring Recovery" two times per day; Psychiatric focused group such as "Mindfulness, Creative Expressions, Coping with Change, Music Therapy" two times per day. The facility also offered AA/NA meetings each night at 8:00 p.m. Patient B14 was assigned to the psychiatric focused group. Patients were expected to attend at one of the two groups scheduled in the morning and afternoon each day.

4. Patient was observed in [his/her] bedroom on 12/21/15 at 11:10 a.m. The group "mindfulness" was on the unit schedule to be held at 11:00 a.m.

5. When asked if patient B14 was supposed to be in that group, RN #2 stated, "[S/he] doesn't go to many group. [S/he] is still pretty confused."

6. A review of the "7-3 Round Checklists" for the period 12/13/15 through 12/21/15 show the following location of patient during times groups were being held.

a. 10/13/15 from 10 a.m. -12 p.m.: "In north hall; on assault precaution."

b. 10/14/14 from 10 a.m. - 12 p.m.: "In north hall"

c. 10/15/15 from 10 a.m. - 12 p.m.: "Room Awake or in North Hall."

d. 10/16/15 from 10 a.m. - 12 p.m.: "In Room or in North Hall."

e. 10/17/15 from 10 a.m. - 12 p.m.: "On assault precaution, Room Awake, or in North Hall."

f. 10/18/15 from 10 a.m. - 12 p.m.: "Bathroom, Room Awake, or in North Hall."

g. 10/19/15 from 10 a.m. - 12 p.m.: "Room Awake (most of the time) or North Hall."

h. 10/20/15 from 10 a.m. - 12 p.m.: "Map room (most of the time) or Room awake."

i. 10/21/14 from 10 a.m. - 12 p.m.: "Room Awake or Room asleep (most of time)."

7. In an interview on 12/22/15 at 2:40 p.m., the lack of patient B14's attendance at groups was discussed with the Director of Allied Therapy. When asked about one to one alternatives when the patient does not attend groups, she stated, "Allied therapy staff don't do one to one." She admitted that the MTP was not revised to reflect alternatives. However, she reported that a note is made on the "orange sheet" regarding engaging the patient to encourage to attend groups.

C. Active sample patient C3

1. Patient C3 was admitted on 11/3/15. The Psychiatric Evaluation, dated 11/3/15, documented that "C3 was a 49 y/o [year/old] presenting here on a 302[5day involuntary commitment]." "Patient states that s/he had been getting more depressed & [and] irritable. Patient stated that s/he has been more on edge. Patient admits to [eligible word] others. Patient denies any AH/ VH [Auditory Hallucinations/Visual Hallucinations]. Patient denies changes in sleep or appetite but later admits to not sleeping. During interview, s/he has looseness of association."

2. The only modalities on C3's MTP, dated 12/16/15 were: "Medication management, group therapy, patient education and allied therapy. There was no mention of alternative measures to be started in place of the groups not being consistently attended by the patient."

3. Patient C3 was observed on 12/21/15 at 11:45 a.m. wandering the hallways. When asked what s/he thought of the care at the facility, s/he stated, "They don ' t do nothing for me." When asked if s/he attended groups, the patient stated, "I just mind my own business."

4. The nursing shift assessments and flow sheet, dated 11/13/15 at 10:50 a.m. stated, "Pt. was withdrawn to his/her room most of the day and didn't interact with others. S/he seemed to be preoccupied"---"talked to his/herself. S/he was not cooperative for an interview, was hostile."

Nursing note, dated 11/14/15 at 1:00 a.m. stated "Pt. did not come up to the medication window and remained secluded to his/her room for the entire shift. Bedtime meds were brought to his/her room."

Nursing note on 11/15/15 at 1 p.m. stated "Pt. wasn't able to engage in reality based conversation, but was observed being withdrawn to self today"---"encouraged to attend groups and be compliant w/med [with medications] regimens."

Nursing note, dated 11/16/15 at 12:55 p.m., stated, "Paranoid and seclusive to self. Brief reality based conversation."

Nursing note, dated 11/17/15 at 9:30a.m. stated "Attempting to engage [name of patient] in a reality based conversation, however, [name of patient] was withdrawn to him/herself and remained non-verbal. Encouraged [name of patient] to attend groups."

D. Active sample patient C9

1. Patient C9 was admitted on 12/14/15. The Psychiatric Evaluation, dated 12/14/15, documented that, "Patient C9 is 43 yrs. [years] old Korean [male/female] with past psych hx. [psychiatric history] of schizophrenia. Was brought in by EMS [Emergency Medical Service] under 302 petition filed by his/her brother for aggressive behavior, threatening family constantly in the context of several psychosocial stressors, including non-compliant with medication, chronic mental illness and unemployment. Pt. is a poor historian and very disorganized. Pt. appears unpredictable"---"Pt. has been 5 - 6 wks. [weeks] off meds. [S/he] stopped taking them, aggressively hostile, threatening family, believing people are spying /watching [him/her]."

2. The only modalities identified on patient C9's MTP, dated 12/15/15, were general ones such as "medication review, individual counseling," and "patient education." There was no mention of alternatives to be included on the MTP to substitute for the patient not going to groups.

3. The patient was observed on 12/21/15 around 11:30 a.m., lying in bed with covers over his/her head. The group taking place on North Hall, which was close to ending, was "CO-Occurring Recovery."

4. When asked why patient C9 was not in group, MHT #1 stated, on 12/21/15 around 10:35 a.m., that s/he spends most of his/her time in room.

5. The "Nursing Shift Assessment and Flow Sheet", dated 12/15/15 at 10 p.m. stated "Pt. remains withdrawn to bed preoccupied in thought. Pt. was encouraged to join community. Pt. did get out of bed and walk away from this RN stating "I'm going this way." Nursing note on 12/16/15 at 2:15 p.m., stated, "Pt. was withdrawn to his/her room most of day. Pt. was encouraged to attend group"--- "Pt. nonverbal for the interview." Nursing note on 12/17/15 at 10:20 a.m., stated, "Pt. was observed keeping to him/herself in his/her room most of the day. When asked why s/he was not attending groups, s/he responded "I just don't want [sic]." Nursing note, dated 12/19/15 at 12:00a.m., stated "Patient was withdrawn [sic] to bed asleep the majority of the shift."

6. In an interview on 12/22/15 around 11:50 a.m., the lack of patient C9's attendance at groups was discussed with MD #2. She was told no alternative interventions were found on his/her MTP. MD #2 stated, "S/he's due to have a treatment team update today. I will bring this up at the meeting. His/her brother wants to come to a treatment team meeting. I will address the patient's isolation with him."


Based on record review and interview, the facility failed to ensure that physician orders were written for use of seclusion and/or restraints for five (5) of five (5) non-sample patients (E1, E2, E3, E4, and E5) whose records were reviewed for adherence to facility policy on seclusion/restraints. This failure results in a violation of patients' rights to be maintained in the least restrictive environment.

Findings include:

A. Record Review

1. Facility policy, no number, dated 12/17/15, titled "Seclusion and Restraint Policy and Procedure", stated "A time limited written order by a physician is necessary for any use of seclusion or restraint. Orders must be incident specific. PRN orders may not be used."

2. The following patient's seclusion or restraint incidents were reviewed for compliance with seclusion/restraint protocol per facility. Policy (dates & types of S/R in parenthesis): E1 (seclusion on 12/11/15 at 5:30 p.m.), E2 (seclusion on 11/10/15 at 1:40 p.m.), E3 (4 pt. [point]) restraint on 11/6/15 at 7:50 a.m.), E4 (4 pt. restraint on 12/2/15 at 10:45 a.m.), and E5 (seclusion on 11/19/15 at 5:10 p.m.). None of the Seclusion/Restraint incidents had a physician order.

B. Interview

In an interview on 12/22/15 at 1:05 p.m., the lack of physician orders for seclusion and restraint use was discussed with the Medical Director. He did not dispute the findings.

Based on record review and interview, the facility failed to ensure that patient discharge summaries were completed in a timely fashion defined by hospital policy requirements for five (5) of five (5) discharged patients (D1, D2, D3, D4, and D5) whose records were reviewed for facility compliance with the policy. This failure compromises the effective transfer of the patients' care to the next care provider.

Findings include:

A. Record Review

1. Facility policy, no number, titled "Discharge Summary Policy Procedure," dated 8/15, stated: "The primary attending physician, certified nurse practitioner, licensed psychologist shall complete summary within 30 days of discharge."

2. The discharge summaries of the following five (5) patients (dates of discharge in parenthesis) whose records were reviewed for discharge summary requirements did not have a summary completed on the closed charts as of 12/21/15: D1 (11/20/15), D2 (11/19/15), D3 (11/19/15), D4 (11/19/15) and D5 (11/20/15).

B. Interview

In an interview on 12/22/15 at 1:05 p.m., the lack of discharge summaries on patients' charts within 30 days of leaving the facility was discussed with the Medical Director. S/he stated, "We're aware of this. With the number of staff (physicians) I have, we can't keep up with the paper work."

Based on record review and interview, the Medical Director failed to monitor the quality of care provided by the various disciplines. Specifically, the Medical Director failed to:

I. Provide comprehensive Master Treatment Plans that reflected appropriate active treatment to be given to patients and provided by the facility staff. Specifically, the facility failed to provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary components to provide active treatment. The MTPs were missing the following components:

A. Clearly defined inventory of patients' strengths/assets and problem statements written in behavioral and descriptive term. Specifically, the MTPs included a short list of vague patient traits or external support resources labeled as "strengths," which results in poorly defined goals and interventions for seven (7) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, and C9). In addition, many of the stated problems on the treatment plans included diagnoses and/or generalized lists of symptoms instead of specific individualized and descriptive clinical symptoms/behaviors for six (6) of eight (8) active sample patients (A9, B14, B16, B20, C3, and C21). These failures can adversely affect clinical decision-making in formulating goal and intervention statements and results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems. (Refer to B119)

B. Individualized short-term goals in observable and behavioral terms for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9 and C21). Long-term goals were often vague statements and did not spell out for the staff the specific behaviors the patient was expected to achieve. The short-term goals were frequently not stated in observable, measureable behavioral terms. (Refer to B121)

C. Individualized and specific active treatment interventions for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9 and C21). (Refer to B122)

D. The name of staff persons responsible for the specific aspects of care (interventions) listed on MTPs foreight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9, and C21). (Refer to B123)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patients' active treatment needs not being met.

II. Ensure that active treatment interventions listed on the treatment plan and/or unit schedule were documented by registered nurses, social workers, and allied therapy staff to include the patients' participation or non-participation, specific topics discussed, and the patients' behavior during interventions, and their response to the intervention, including level of participation, understanding, and specific comments for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9, and C21). This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124)

III. Provide active treatment, including alternative interventions for four (4) of eight (8) active sample patients (A9, B14, C3, and C9) who were either not cognitively capable of participating in treatment at times or were not motivated to attend all groups listed on each unit's activity schedule. The patients regularly and repeatedly did not attend group therapies. These patients spent many hours either wandering the halls or lying on their beds. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals and objectives, potentially delaying their improvement. (Refer to B125I)

VI. Ensure that physician orders were written for use of seclusion and/or restraints for five (5) of five (5) non-sample patients (E1, E2, E3, E4, and E5) whose records were reviewed for adherence to facility policy on seclusion/restraints. This failure results in a violation of patients' rights to be maintained in the least restrictive environment. (Refer to B125II)

Based on observation, record review, and interview, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to:

I. Develop individualized Master Treatment Plans (MTPs) that clearly delineated active treatment nursing interventions to address specific patient problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9 and C21). Specifically, MTPs failed to include a focus of treatment based on each patient's presenting symptoms and to consistently identify the method of delivery for each intervention. Most of the nursing interventions were included under those assigned to the entire treatment team. These deficiencies potentially result in nursing staff being unable to provide consistent and focused active treatment.

Findings include:

A. Record Review

1. Active sample patient A5's MTP dated 12/315 and update 12/9/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Unable to care for self. Evidenced/Triggered by: not taking his blood pressure or diabetic meds [medications], not sleeping."

Treatment Team: "Patient education"

Problem 2: "Non adherence to medication/tx [treatment]. Evidenced/Triggered by:...refusing oral medication and remains withdrawn to room, is suspicious and RIS [XX]..."

Treatment Team: "Encourage [Patient's name] to be an active participant with treatment."

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statement regarding patient education did not include whether the interventions would be delivered in individual or group sessions. The intervention statements regarding encouraging the patient was generic and non-specific and would be done by nursing staff for any patient regardless of the patient's presenting symptoms.

2. Active sample patient A9's MTP dated 12/7/15 had the following intervention for the identified psychiatric problem (called challenges by the facility):

Problem 1: "Unable to care for self. Evidenced/Triggered by: patient is disorganized and disrobing in the crisis center."

Treatment Team: "Patient education"

The intervention statement above did not include a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statement also did not include whether the intervention would be delivered in individual or group sessions.

3. Active sample patient B14's MTP dated 12/11/15 had the following interventions for the identified psychiatric problem (called challenges by the facility):

Problem 1: "Unable to care for self. Evidenced/Triggered by: malodorous, disshelved, disorganized thought."

Nursing: "Monitor ADL's"

Treatment Team: "Individual counseling"

The intervention statement regarding individual counseling did not include a focus of treatment based on this patient's presenting problems and/or treatment goals. This intervention statement also did not include a delivery method. The intervention statement regarding monitoring ADLs was actually a nursing task not a treatment intervention reflecting what nursing would be to assist the patient to improve his/her presenting problems.

4. Active sample patient B16's MTP dated 12/11/15 and update 12/18/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Disorganized behavior. Evidenced/Triggered by: pt. [patient] assaulted by boy/girlfriend and making illogical statements."

Treatment Team Intervention: "Individual Counseling"

Problem 2: "Alcohol abuse. Evidenced/Triggered by: [Patient's name] reports that she recently had 4 cans of beer and [s/he] was 'manipulated by [him/her] to drink'."

Treatment Team: "Educate on the negative effects of alcohol use."

The intervention statement regarding individual counseling did not include a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statement regarding alcohol use did not include whether the intervention would be delivered in individual or group sessions.

5. Active sample patient B20's MTP dated 10/7/15 and last updated 12/17/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 2: "Impulsive behaviors leading to dangerous situations (i.e. getting angry and running into traffic)."

Treatment Team Intervention: "Monitor for safety, re-direct as needed." "Offer support and education on the dangerousness of running into traffic/acting out when upset." "Encourage active group participation, offer 1:1 support as needed." "Offer support and provide education on the benefits of additional support."

Problem 3: "Maintaining safety on the unit. Evidenced/Triggered by: [Patient's name] running in the hallway, and tripping/falling."

Treatment Team Intervention: "Reinforce the dangers of running on the unit. Encourage [Patient's name] to wear sneakers, and to walk. Redirect as needed."

Problem 4: "Maintaining in the community. Evidenced/Triggered by: Frequent hospitalization and police intervention."

Treatment Team Intervention: "Encourage active group participation." "Assist in identifying ways to stay safe."

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements also did not include whether the intervention would be delivered in individual or group sessions. The intervention statements regarding encouraging and redirecting the patient were nursing tasks not treatment interventions to assist the patient to make improvements in the presenting symptoms.

6. Active sample patient C3's MTP dated 12/16/15 included the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "threatening others. Evidenced/Triggered by: pt. [patient] admits to having thoughts of harming others."

Treatment Team Intervention: "Patient education" "Meet with [Patient] daily to discuss stressors and the importance of medication compliance."

Problem 2: "Paranoid Delusions. Evidenced/Triggered by: Per record of events PTA and current presentation."

Treatment Team: "Monitor status, redirecting as necessary."

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements also did not include whether the intervention would be delivered in individual or group sessions. The intervention statements regarding monitoring and redirecting were nursing tasks not treatment interventions to assist the patient to make improvements in the presenting symptoms.

7. Active sample patient C9's MTP dated 12/15/15 had the following interventions for the identified problem (called challenges by the facility):

Problem 1: "Thought Disorder. Evidenced/Triggered by: Per 302, pt. [patient] believes people are watching or spying on [him/her]."

Treatment Team Intervention: "Individual Counseling"

The intervention statement above did not include a focus of treatment based on this patient's presenting problems and/or treatment goals.

8. Active sample patient C21's MTP dated 12/18/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Suicidal. Evidenced/Triggered by: suicidal statements prior to admission. Notes: 'no, that's just babbling cause I was drunk. I am not suicidal."

Treatment Team Intervention: "Individual Counseling"

Problem 2: "Substance use. Evidenced/Triggered by: [Patient's name] report of recent alcohol binge and cocaine use. UDS [Urine Drug Screen] + for cocaine, benzodiazepine and barbituates [sic]."

Problem 3: "Depression and Anxiety. Evidenced/Triggered by: [Patient's name] report"

Treatment Team: "Patient education and support"

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements regarding patient education also did not include whether the intervention would be delivered in individual or group sessions.

B. Interview

In an interview on 12/22/15 at 1:35 p.m., with the Director of Nursing the MTPs for the active sample patients were discussed. She acknowledged that interventions did not include a focus of treatment and failed to identify whether the interventions would be conducted in individual or group sessions. She also agreed that interventions such as monitoring, encouraging, and redirecting patients were nursing tasks not treatment interventions to assist the patient to improve presenting symptoms.

Based on record review and staff interview, the Director of Social Work failed to:

I. Ensure social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (A5, A9, B14, B16, B20, C3, C9, and C21). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Based on record review and interview, the facility failed to develop individualized Master Treatment Plans (MTPs) that clearly delineated social work staff interventions to address specific patient problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A5, A9, B14, B16, B20, C3, C9 and C21). Specifically, MTPs failed to include a focus of treatment based on each patient's presenting symptoms and to consistently identify the method of delivery for each intervention. Most of the nursing interventions were included under those assigned to the entire treatment team. These deficiencies potentially result in social work staff being unable to provide consistent and focused active treatment.

Findings include:

A. Record Review

1. Active sample patient A5's MTP dated 12/315 and update 12/9/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Unable to care for self. Evidenced/Triggered by: not taking his blood pressure or diabetic meds [medications], not sleeping."

Treatment Team: "Patient education"

Problem 2: "Non adherence to medication/tx [treatment]. Evidenced/Triggered by: ...refusing oral medication and remains withdrawn to room, is suspicious and RIS [Responding to internal stimuli]..."

Treatment Team: "Encourage [Patient's name] to be an active participant with treatment."

The intervention statements above did not include a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statement regarding patient education also did not include whether the intervention would be delivered in individual or group sessions. The intervention statement regarding encouraging was a social work task not a treatment intervention to assist the patient to make improvements in the presenting symptoms.

2. Active sample patient A9's MTP dated 12/7/15 had the following interventions for the identified psychiatric problem (called challenges by the facility):

Problem 1: "Unable to care for self. Evidenced/Triggered by: patient is disorganized and disrobing in the crisis center."

Treatment Team: "Patient education"

The intervention statement above include a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statement also did not include whether the intervention would be delivered in individual or group sessions.

3. Active sample patient B14's MTP dated 12/11/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Unable to care for self. Evidenced/Triggered by: malodorous, disshelved, disorganized thought."

Treatment Team: "Individual counseling"

The intervention statement above did not include a focus of treatment based on this patient's presenting problems and/or treatment goals.

4. Active sample patient B16's MTP dated 12/11/15 and update 12/18/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Disorganized behavior. Evidenced/Triggered by: pt. [patient] assaulted by boy/girlfriend and making illogical statements."

Treatment Team Intervention: "Individual Counseling"

Problem 2: "Alcohol abuse. Evidenced/Triggered by: [Patient's name] reports that she recently had 4 cans of beer and [s/he] was 'manipulated by [him/her] to drink'."

Treatment Team: "Educate on the negative effects of alcohol use."

The intervention statement regarding individual counseling did not include a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statement regarding alcohol did not include whether the intervention would be delivered in individual or group sessions.

5. Active sample patient B20's MTP dated 10/7/15 and last updated 12/17/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 2: "Impulsive behaviors leading to dangerous situations (i.e. getting angry and running into traffic)."

Treatment Team Intervention: "Monitor for safety, re-direct as needed." "Offer support and education on the dangerousness of running into traffic/acting out when upset." "Encourage active group participation, offer 1:1 support as needed." "Offer support and provide education on the benefits of additional support."

Social Services Intervention: "Contact family and OP [Outpatient] supports, arrange meeting, facilitate meeting." "Research appropriate locations, coordinate with family and OP [Outpatient] supports; arrange discharge when appropriate."

Problem 3: "Maintaining safety on the unit. Evidenced/Triggered by: [Patient's name] running in the hallway, and tripping/falling."

Treatment Team Intervention: "Reinforce the dangers of running on the unit. Encourage [Patient's name] to wear sneakers, and to walk. Redirect as needed."

Problem 4: Maintaining in the community. Evidenced/Triggered by: Frequent hospitalization and police intervention.

Treatment Team Intervention: "Encourage active group participation." "Assist in identifying ways to stay safe."

Social Services Intervention: "Assist in identifying resources."

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements also did not include whether the intervention would be delivered in individual or group sessions. The intervention statements regarding encouraging and redirecting the patient were social work tasks not treatment interventions to assist the patient to make improvements in the presenting symptoms.

6. Active sample patient C3's MTP dated 12/16/15 included the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "threatening others. Evidenced/Triggered by: pt. [patient] admits to having thoughts of harming others."

Treatment Team Intervention: "Patient education" "Meet with [Patient] daily to discuss stressors and the importance of medication compliance."

Social Services: "Continue to attempt to engage [Patient's name] in treatment related discussion."

Problem 2: "Paranoid Delusions. Evidenced/Triggered by: Per record of events PTA and current presentation."

Social Services: "Connect without patient support system, coordinate meeting with staff and treatment team." "Patient education. Disposition planning." "Continue to coordinate treatment plans and meetings with CHS LTRS staff and [his/her] PO prior to discharge."

Treatment Team: "Monitor status, redirecting as necessary."

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statements also did not include whether the intervention would be delivered in individual or group sessions. The intervention statements regarding monitoring and redirecting were nursing tasks not treatment interventions to assist the patient to make improvements in the presenting symptoms.

7. Active sample patient C9's MTP dated 12/15/15 had the following interventions for the identified problem (called challenges by the facility):

Problem 1: "Thought Disorder. Evidenced/Triggered by: Per 302, pt. [patient] believes people are watching or spying on [him/her]."

Treatment Team Intervention: "Individual Counseling"

The intervention statement above did not include a focus of treatment based on this patient's presenting problems and/or treatment goals.

8. Active sample patient C21's MTP dated 12/18/15 had the following interventions for the identified psychiatric problems (called challenges by the facility):

Problem 1: "Suicidal. Evidenced/Triggered by: suicidal statements prior to admission. Notes: 'no, that's just babbling cause I was drunk. I am not suicidal."

Treatment Team Intervention: "Individual Counseling"

Problem 2: "Substance use. Evidenced/Triggered by: [Patient's name] report of recent alcohol binge and cocaine use. UDS [Urine Drug Screen] + for cocaine, benzodiazepine and barbituates [sic]."

Social Services: "Patient Education."

Problem 3: "Depression and Anxiety. Evidenced/Triggered by: [Patient ' s name] report"

Treatment Team: "Patient education and support"

None of the intervention statements above included a focus of treatment based on this patient's presenting problems and/or treatment goals. The intervention statement regarding patient education also did not include whether the intervention would be delivered in individual or group sessions.

C. Interview

In an interview on 12/22/15 at xx with the Director of Social Work, the MTPs for the active sample patients were discussed. She agreed that there were no interventions regarding assisting the patient to complete anticipated steps for discharge included on the
MTP for Patient A5, B14, B16, and C9. She acknowledge that the interventions on the MTP assigned to the entire treatment team included social work staff.