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Based on record review, interview, and policy review the facility failed to identify a diagnosis that served as the primary focus for the treatment plans of two (2) of eight (8) active sample patients (patients 1, and 2). This failure compromised the staff's ability to deliver clinically focused treatment.

Findings include:

A. Record Review


1. Patient 1, admitted 10/8/15 with diagnoses of posttraumatic stress disorder, major depression, opiate withdrawal, opiate dependence, amphetamine dependence, and marijuana abuse and treatment plan developed 10/9/15, did not identify a diagnosis on the treatment plan.

2. Patient 2, admitted 10/8/15 with diagnoses of opioid dependence with withdrawal (active), s,h,a [sedative, hypnotic, anxiolytic] dependence uncomplicated (active), [other substance] dependence in remission (active), cannabis dependence, and bipolar disorder, current episode depressed, moderate (active) and treatment plan developed 10/9/15, did not identify a diagnosis on the treatment plan.

B. Interview

In an interview on 10/13/15 at 10:30 a.m., Director of Social Services confirmed that no diagnoses were identified on the treatment plans.

C. Policy Review

Hospital policy PC-222, Interdisciplinary Treatment Plan (ITP), developed 5/12 states under section B-1 "Treatment Planning Forms" that Axis I and Axis III diagnoses will be listed on the Problem List.

Based on record review, interview and policy review the facility failed to identify specific treatment interventions based on the individual needs of the patient for eight (8) of eight (8) sample patients (1, 2, 3, 4, 5, 6, 7 and 8). This failure resulted in staff being unable to provide focused, individualized treatment for patients' identified problems.

Findings include:


A. Record Review

1. Patient 1 (master treatment plan dated 10/9/15) had the following interventions for the Short Term Goal, "Pt. [patient] will attend group therapy sessions to identify 1-3 triggers that increase substance use within 4 days":

"Nurse will administer medication for substance abuse and/or withdrawal symptoms and monitor and record compliance, symptoms and side effects. This will occur 2-8 times per day and will last for 45 minutes."

"Prescriber will examine patient and order consultations and lab as needed to arrive at all appropriate diagnoses and order medication as appropriate. This will occur once per day and will last as needed."

"OT/PT/recreational activity to encourage socialization and to find other sources of pleasure and meaning. This will occur 1-4 times per day and will last 45 minutes."

"Group Therapy Meetings designed to help promote understanding of circumstances and feelings which lead to substance abuse. This will occur twice per day and will last for 45 minutes."

These interventions are generic, job description duties and are not individualized for the specific patient.

2. Patient 2 (master treatment plan dated 10/9/15) had the following interventions for the short term goal, "Pt. [patient] will describe 2 negative consequences that arose as a result of substance use within 3 day":

"Group Therapy Meetings designed to help promote understanding of circumstances and feelings which lead to substance abuse. This will occur twice per day and will last for 45 minutes."

"OT/PT/recreational activity to encourage socialization and to find other sources of pleasure and meaning. This will occur 1-4 times per day and will last for 45 minutes."

"Prescriber will examine patient and order consultations and lab as needed to arrive at all appropriate diagnoses and order medication as appropriate. This will occur once per day and will last as needed."

"Nurse will administer medication for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects. This will occur 2-8 times per day and will last as indicated."

These interventions are generic, job description duties and are not individualized for the specific patient.

3. Patient 3 (master treatment plan dated 10/13/15) had the following interventions for the short term goal, "[Patient] will have a decrease in symptoms of disorganized behavior for a period of 3 days":

"Prescriber will examine patient and order consultations and lab as needed to arrive at all appropriate diagnoses. This will occur once per day and will last as needed."

"Nurse will actively engage patient and encourage participation in activities. This will occur 1-4 times per day and will last as indicated."

"OT/PT/ RT activity to allow patient to express feelings through activity and interactions with others. This will occur 1-4 times per day and will last for 45 minutes."

"Group Therapy 1x per day to increase adaptive social functioning. This will occur twice per day and will last for 45 minutes."

These interventions are generic, job description duties and are not individualized for the specific patient.

4. Patient 4 (master treatment plan dated 10/12/15) had the following interventions for the short term goal, "[Patient] will identify 1-3 triggers that increase substance use":

"OT/PT/recreational activity to encourage socialization and to find other sources of pleasure and meaning. This will occur 1-4 times per day and will last for 45 minutes."

"Prescriber will examine patient and order consultations and lab as needed to arrive at all appropriate diagnoses and order medication as appropriate. This will occur once per day and will last as needed."

"Nurse will administer medication for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects. This will occur 1-4 times per day and will last as indicated."

"Therapist will provide education, emotional support, and community resources to maintain stability and reduce symptoms within individual and group therapy. This will occur twice per day and will last for 45 minutes."

These interventions are generic, job description duties and are not individualized for the specific patient.

5. Patient 5 (master treatment plan dated 10/12/15) had the following interventions for the short term goal, "[Patient] will not exhibit any signs of hallucinations or paranoia":

"OT/PT/recreational activity to encourage socialization and to find other sources of pleasure and meaning. This will occur 1-4 times per day and will last for 45 minutes."

"Prescriber to prescribe medications, monitor side effect, and adjust dosage to minimize or eliminate psychotic symptoms and minimize side effects. This will occur once per day and will last as needed."

"Nurse will administer medication for psychotic process and monitor and record compliance, symptoms and side effects. This will occur 1-4 times per day and will last as indicated."

"Therapist will provide education, emotional support and community resources to maintain stability and reduce symptoms within individual and group therapy. This will occur twice per day and will last for 45 minutes."

These interventions are generic, job description duties and are not individualized for the specific patient.

6. Patient 6 (master treatment plan dated 10/12/15) had the following interventions for the short term goal, "[Patient] will be free of thoughts of death or suicide for at least 2 days":

"Nurse will actively engage patient and encourage participation in activities. This will occur 1-4 times per day and will last as indicated."

"Prescriber to prescribe medications, monitor side effect, and adjust dosage to stabilize mood and minimize side effects. This will occur once per day and will last as needed."

"OT/PT/recreational activity to encourage socialization and to find other sources of pleasure and meaning. This will occur 1-4 times per day and will last for 45 minutes."

"Therapist will provide education, emotional support and community resources to maintain stability and reduce symptoms within individual and group therapy. This will occur twice per day and will last for 45 minutes."

These interventions are generic, job description duties and are not individualized for the specific patient.

7. Patient 7 (master treatment plan dated 10/13/15) had the following interventions for the short term goal, "[Patient] will develop a list of reasons to avoid drugs prior to discharge":

"Prescriber will examine patient and order consultations and lab as needed to arrive at all appropriate diagnoses and order medication, as appropriate."

"Nurse will administer medication for substance abuse and/or withdrawal symptoms and monitor and record compliance, symptoms and side effects."

"OT/PT/recreational activity to encourage socialization and to find other sources of pleasure and meaning to replace substance abuse."

"Therapist will provide education on sobriety, emotional support and community resources to maintain stability and reduce symptoms within individual and group therapy."

These interventions are generic, job description duties and are not individualized for the specific patient.

8. Patient 8 (master treatment plan dated 10/13/15) had the following interventions for the short term goal, "Patient will verbalize 1-3 triggers that increase depressive symptoms within 3 days":

"Nurse will actively engage patient and encourage participation in activities. This will occur 1-4 times per day and will last as indicated."

"OT/PT/REC activity to foster sense of self-worth via artistic expression and interactions with others. This will occur 1-4 times per day and will last for 45 minutes."

"Prescriber to prescribe medications, monitor side effects and adjust dosage to stabilize mood and minimize side effects. This will occur once per day and will last as needed."

"Therapist will provide education, emotional support and community resources to maintain stability and reduce symptoms within individual and group therapy. This will occur twice per day and will last for 45 minutes."

These interventions are generic, job description duties and are not individualized for the specific patient.

B. Interview

1. On 10/12/15 at 1:20 p.m., the Director of Nursing stated, "Yes, I agree. The interventions are mostly all the same and are not individualized."

2. On 10/13/15 at 10:45 a.m., The Director of Social Work stated, "I can see that the interventions are not individualized."

3. On 10/13/15 at 2:00 p.m., The Clinical Director stated, "The interventions are not individualized."

C. Policy


Facility policy PC-222 titled "Interdisciplinary Treatment Plan and dated 5/12 states, "The treatment plan shall be individualized to meet the patient's unique needs and circumstances as identified through assessment data and patient/family input to the extent possible, and shall be appropriate to the patient's needs."

Based on record review, interview and policy review, the facility failed to ensure that the staff member responsible for each intervention was specifically identified in eight (8) of eight (8) sample treatment plans (Patients 1, 2, 3, 4, 5, 6, 7, and 8). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented.

Findings:

A. Record Review

1. Patient 1 (Master Treatment Plan dated 10/9/15) had no staff names for any interventions.

2. Patient 2 (Master Treatment Plan dated 10/9/15) had no staff names for any interventions.

3. Patient 3 (Master Treatment Plan dated 10/13/15) had no staff names for any interventions.

4. Patient 4 (Master Treatment Plan dated 10/12/15) had no staff names for any interventions.

5. Patient 5 (Master Treatment Plan dated 10/12/15) had no staff names for any interventions.

6. Patient 6 (Master Treatment Plan dated 10/12/15) had no staff names for any interventions.

7. Patient 7 (Master Treatment Plan dated 10/13/15) had no staff names for any interventions.

8. Patient 8 (Master Treatment Plan dated 10/13/15) had no staff names for any interventions.

B. Interview

1. On 10/12/15 at 1:20 p.m. the Director of Nursing stated, "No, there are no staff names for the treatment plan interventions."

2. On 10/13/15 at 10:45 p.m. the Director of Social Services stated, "You are correct. We do not have staff names for the interventions."

3. On 10/13/15 at 2:00 p.m. the Clinical Director stated, "No, we do not have the staff names on the intervention. We can correct that."

C. Policy

Facility Policy (PC-222) titled, "Interdisciplinary Treatment Plan" and dated 5/12 states, "The interventions must be [sic] include the following: Responsible Staff (the name(s) and discipline of the specific staff member responsible for the provision of the intervention)."

Based on record review, observation, and interviews, the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility.

The Medical Director failed to ensure that:

I. A diagnosis that served as the primary focus for the treatment plans was identified for two (2) of eight (8) active sample patients. (refer to B120)

II. The facility failed to identified specific treatment interventions based on the individual needs of the patient for eight (8) of eight (8) sample patients. (refer to B122)

III. That the staff member responsible for each intervention was specifically identified in eight (8) of eight (8) sample treatment plans. (refer to B123)

Based on record review, interview and policy review, the Director of Nursing failed to ensure that eight (8) out of eight (8) sample treatment plans contained individualized nursing interventions and that nursing interventions included the responsible staff's name. This deficiency resulted in specific, named nursing staff being unable to provide focused, individualized care based on the patients' needs.

A. Record Review

1. Patient 1 (master treatment plan dated 10/9/15) had the following nursing intervention for the Short Term Goal, "Pt. [patient] will attend group therapy sessions to identify 1-3 triggers that increase substance use within 4 days":

"Nurse will administer medication for substance abuse and/or withdrawal symptoms and monitor and record compliance, symptoms and side effects. This will occur 2-8 times per day and will last for 45 minutes."

This intervention is a generic, job description duty and is not individualized for the specific patient. The nursing staff responsible for this intervention is not named.

2. Patient 2 (master treatment plan dated 10/9/15) had the following nursing intervention for the short term goal, "Pt. [patient] will describe 2 negative consequences that arose as a result of substance use within 3 day":

"Nurse will administer medication for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects. This will occur 2-8 times per day and will last as indicated."

This intervention is a generic, job description duty and is not individualized for the specific patient. The nursing staff responsible for this intervention is not named.

3. Patient 3 (master treatment plan dated 10/13/15) had the following nursing intervention for the short term goal, "[Patient] will have a decrease in symptoms of disorganized behavior for a period of 3 days":

"Nurse will actively engage patient and encourage participation in activities. This will occur 1-4 times per day and will last as indicated."

This intervention is a generic, job description duty and is not individualized for the specific patient. The nursing staff responsible for this intervention is not named.

4. Patient 4 (master treatment plan dated 10/12/15) had the following interventions for the short term goal, "[Patient] will identify 1-3 triggers that increase substance use":

"Nurse will administer medication for substance abuse and/or withdrawal symptoms and monitor and record compliance, symptoms and side effects. This will occur 1-4 times per day and will last as indicated.

This intervention is a generic, job description duty and is not individualized for the specific patient. The nursing staff responsible for this intervention is not named.

5. Patient 5 (master treatment plan dated 10/12/15) had the following nursing intervention for the short term goal, "[Patient] will not exhibit any signs of hallucinations or paranoia":

"Nurse will administer medication for psychotic process and monitor and record compliance, symptoms and side effects. This will occur 1-4 times per day and will last as indicated."

This intervention is a generic, job description duty and is not individualized for the specific patient. The nursing staff responsible for this intervention is not named.

6. Patient 6 (master treatment plan dated 10/12/15) had the following nursing intervention for the short term goal, "[Patient] will be free of thoughts of death or suicide for at least 2 days":

"Nurse will actively engage patient and encourage participation in activities. This will occur 1-4 times per day and will last as indicated."

This intervention is a generic, job description duty and is not individualized for the specific patient. The nursing staff responsible for this intervention is not named.

7. Patient 7 (master treatment plan dated 10/13/15) had the following nursing intervention for the short term goal, "[Patient] will develop a list of reasons to avoid drugs prior to discharge":

"Nurse will administer medication for substance abuse and/or withdrawal symptoms and monitor and record compliance, symptoms and side effects."

This intervention is a generic, job description duty and is not individualized for the specific patient. The nursing staff responsible for this intervention is not named.

8. Patient 8 (master treatment plan dated 10/13/15) had the following nursing intervention for the short term goal, "Patient will verbalize 1-3 triggers that increase depressive symptoms within 3 days":

"Nurse will actively engage patient and encourage participation in activities. This will occur 1-4 times per day and will last as indicated."

This intervention is a generic, job description duty and is not individualized for the specific patient. The nursing staff responsible for this intervention is not named.

B. Interview

On 10/12/15 at 1:20 p.m., the Director of Nursing stated, "Yes, I agree. The interventions are mostly all the same and are not individualized. No, there are no staff names for the treatment plan interventions."

C. Policy

Facility policy PC-222 titled "Interdisciplinary Treatment Plan and dated 5/12 states, The treatment plan shall be individualized to meet the patient's unique needs and circumstances as identified through assessment data and patient/family input to the extent possible, and shall be appropriate to the patient's needs." In addition, it states, "The interventions must include the following: Responsible Staff (the name(s) and discipline of the specific staff member responsible for the provision of the intervention)."