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Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) for five (5) of 12 active sample patients (6, 7, 8, 9, and 10) that included treatment interventions with a specific purpose and focus. Many of the interventions on the treatment plans were listed as generic discipline functions/tasks. Failure to clearly describe specific modalities on patient's MTPs can hamper staff's ability to provide treatment based on individual patient needs.

Findings include

A. Record Review

1. Patient 6

Patient 6's MTP, dated 10/29/2019, had the following problem statement: "Psychosis - disorganized thoughts and behavior, Mood disorder, Alcohol and cocaine abuse, Aggressive behavior, Homeless, Non-compliance, poor insight." The generic physician intervention statement was: "Dr. Prescribe medications, monitor labs and side effects, and efficacy of meds."

2. Patient 7

Patient 7's MTP, dated 11/01/2019, had the following problem statement, "Paranoia, grandiose delusions, aggressive behaviors, history treatment non-compliance and cannabis use/abuse." The generic physician intervention was: "Individual sessions to prescribe medication, assess treatment response and side effects."

3. Patient 8

Patient 8's MTP, dated 10/30/2019, had the following problem statement, "History of Non-compliance with medication, Delusion of grandeur regarding money and owing several businesses and history of Cannabis abuse, history aggressive behavior." The generic physician intervention was: "Staff will monitor labs and aid the patient with recognizing and report medication side effects along with adverse reaction."

4. Patient 9

Patient 9's MTP, dated 5/14/2019, had the following problem statement: "Paranoid Delusions, Perceptual problems, Aggressive/Assaultive behavior. [Patient] has a history of drug and alcohol use." The generic physician interventions were: "RN will monitor Prescribe psychiatric medication and associate [sic] labs. Monitor for efficacy, side effects, therapeutic value. Individual support sessions and pharmacotherapy. Wellness Self-Management psychoeducational group. Patient will not show any paranoia or delusional yelling or cursing will be compliant with [his/her] meds."

5. Patient 10

Patient 10's MTP, dated 9/3/2019, had the following problem statement: "[Patient] has a history of psychiatric symptoms that contributed to [his/her] demonstration of dangerous behavior while in the community. [Patient] currently does not identify as having a mental illness or requiring treatment. Paranoid delusions regarding an international conspiracy targeting [patient] due to [his/her] involvement in a UFO (Unknown Foreign Object) organization persist." The generic physician intervention statement was: "Prescribed medication and associated labs. Monitor for efficacy, therapeutic value, side effects, and adherence."

B. Interview

In an interview on 2/11/2020 at 10:55 a.m. with the Medical Director, the generic interventions were discussed, and he agreed with the findings.