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Based on record review and interview, the facility failed to provide social work assessments that included an evaluation of psychosocial issues with recommendations for social work roles in treatment for 10 of 12 sample patients in the adult units (B1, B5, B15, B19, B20, B21, C5, C11, C47, and C50). This resulted in a document that did not address patient needs and social work interventions necessary for treatment planning.

Findings include:

A. Record Review

1. The psychosocial assessments for patient B1 (dated 7/08/11), Patient B5 (dated 07/07/11), Patient B15 (dated 07/01/11), Patient B19 (dated 05/27/11), Patient B21 (dated 06/15/11), Patient C5 (dated 07/12/11), Patient C11 (dated 06/20/11), Patient C47 (dated 07/01/01), and Patient C50 (dated 07/06/11) did not include an evaluation of psychosocial issues with recommendations for social work roles in treatment.

2. The psychosocial assessment for Patient B20 (dated 07/08/11) could not be completed due to patient's condition. There was no additional document that included an evaluation of psychosocial issues or recommendations for social work roles in treatment.

B. Staff Interview

In an interview 0712/11, 2:00p.m. the Director of Social Work verified the psychosocial assessments did not include recommendations for social work roles

Based on record review, policy review and staff interview, the facility failed to provide Master Treatment Plans (MTPs) for 11 of 12 active sample patients (A4, A9, B1, B5, B15, B19, B21, C5, C11, C47 and C50) that included individualized and focused interventions. The interventions on these patients' MTPs were generic tasks for each discipline instead of individualized interventions based on assessed patient needs. In addition, some of the groups that the patient was to attend were not listed in the intervention section of the MTP but were documented on a "physician's orders/clinical programming" sheet. These interventions had no listed time frame or expected frequency of attendance, and were not related to the listed MTP goals. These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

Findings include:

A. Record Review

1. Patient A4 (MTP initiated 7/6/11). For the problem "aggression," the MTP listed the following generic tasks for the physician, nurse and social worker: The Physician will "prescribe medication"; Nursing will "encourage group participation daily; administer medications as ordered/monitor compliance "; Social Work will "provide leisure education per session"). There was a patient objective to "channel emotions into leisure/sports/fitness based activities" with the modality listed as "per session RT (Recreational Therapy)." Other groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." These group interventions had no listed time frame or frequency of attendance. This resulted in lack of information to determine whether the patient's attendance in group helped him/her to accomplish the short-term objective included in the treatment plan.

2. Patient A9 (MTP initiated 7/9/11). For the problems "psychosis/impulse control," The MTP listed the following generic tasks for the physician, nurse and social worker: The Physician will "prescribe medication; encourage group participation daily"; Nursing will "administer medications as ordered/monitor compliance"; Social Work will "assess mood per session." There was a patient objective to: "participate in 1 leisure activity per session with no evidence of impulsive behavior" with the modality listed for RT Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." The group interventions had no listed time frame or frequency of attendance for the patient to support patient's objective. This resulted in lack of information to determine whether the patient's attendance in group helped him/her to accomplish the short-term objective included in the treatment plan.

3. Patient B1 (MTP initiated 7/7/11). For the problem "depressed mood/ impulse control," the MTP listed the following generic tasks for the physician, nurse, and social worker: The Physician will "educate on medications before discharge"; Nursing will "administer medication as ordered/monitor compliance, educate on medication by discharge"; Social Work will "assess ability (of patient) to remain in group each session." Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." This resulted in lack of information to determine whether the patient's attendance in any group helped him/her to accomplish the short-term objective(s) included in the treatment plan.

4. Patient B5 (MTP initiated 7/5/11). For the problem "psychosis/impulse control," the MTP listed the following generic tasks for the physician, nurse and social worker: The Physician will "encourage group participation daily; monitor medication compliance"; Nursing will "administer medications as ordered/ monitor compliance; assess ability to tolerate groups daily"; Social Work will "assess ability to tolerate group each session." Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." Listed under Clinical Programming for patient B5 was "assess and involve in group therapy." This group intervention did not list a specific group(s), a time frame, frequency of attendance, or rationale for the intervention.

5. Patient B15 (MTP initiated 7/1/11). For the problem "Psychosis," the MTP listed the following generic tasks for the physician, nurse and social worker: The Physician will "prescribe medication"; Nursing will "administer medications as ordered/monitor compliance"; Social Work will "encourage group participation daily." Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." Listed under Clinical Programming for Patient B15 was "assess and involve in group therapy." This group intervention did not list a specific group(s), a time frame, frequency of attendance, or rationale for the intervention.

6. Patient B19 (MTP initiated 6/7/11). For the problems "bipolar" and "non-compliance with treatment," the MTP listed the following generic tasks for the physician, nurse and social worker: The Physician will "prescribe medication"; Nursing will "administer medications as ordered/monitor compliance"; Social Work will "encourage group participation daily." Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." Listed under Clinical Programming for patient B19 were the following groups "Assess and involve in group therapy; Patient Therapeutic Education; Therapeutic Recreation and Mgmt (management) of Mental Illness." This group list of interventions did not specify a time frame, frequency of attendance, or rationale for the interventions.

7. Patient B21 (MTP initiated 6/14/11). For the problems "paranoia" and "non-compliance with medication," the MTP listed the following generic tasks for the physician, nurse, social worker: Physician will "assess thought processes daily"; Nursing will "administer medication as ordered/monitor compliance encourage group participation daily"; Social Work will "assess ability to tolerate group each session." Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." Listed under Clinical Programming for patient B21 was the following group: "Assess and involve in group therapy." This intervention did not specify a time frame, frequency of attendance, or rationale for the interventions.

8. Patient C5 (MTP initiated 7/10//11). For the problem "depressed mood," the MTP listed the following generic tasks for the physician: The Physician will "educate on medications before discharge; assess ability to tolerate groups daily; prescribe medication." Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." Listed under Clinical Programming patient C5 was "assess and involve in group therapy and Spanish spirituality." These group interventions did not include a time frame, frequency of attendance, or rationale for the intervention.

9. Patient C11 (MTP initiated 6/18/11). For the problems "major depression" and "poly-substance abuse," the MTP listed the following generic tasks for the physician, nurse and social worker: The Physician will " prescribe medication, encourage group participation daily"; nursing will "administer medications as ordered/monitor compliance;" Social Work will "assess ability to remain in group each session." Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." Listed under Clinical Programming for patient C11 was the following group "Assess and involve in group therapy." This intervention did not specify a time frame, frequency of attendance, or rationale for the intervention.

10. Patient C47 (MTP initiated 7/1/11). For the problem "depressed mood/substance abuse related disorder," the MTP listed the following generic tasks for the physician, nurse and social worker: The Physician will "prescribe medication, encourage group participation daily"; Nursing will "administer medication as ordered and monitor compliance, encourage group participation daily." Social Work will "provide two positive spiritual responses to deal with anxiety and distress." Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." Listed under Clinical Programming for patient C47 were the following groups: "Assess and involve in group therapy; AA group; Anger management; Life Management Skills; Mood Management; Patient Therapeutic Education; Resource Group; Stress Management; Therapeutic Recreation; Spanish Spirituality." These interventions did not specify a time frame, frequency of attendance, or rationale for the interventions.

11. Patient C50 (MTP initiated 7/5/11). For the problem "depressed mood/risk for suicide," the MTP listed the following generic tasks for the physician, nurse and social worker: The Physician will "encourage group participation daily; prescribe medication, mood stabilizer plus antidepressant;" Nursing will "administer medications as ordered/monitor compliance; encourage group participation daily"; Social Work will "assess ability to remain in group each session." Groups that the patient was to attend were not listed in the intervention section of the MTP but under "physician's orders/clinical programming." Listed under Clinical Programming for patient C50 included the following groups: "Assess and involve in group therapy; AA group; Anger management; Mood Management; Patient Therapeutic Education; Spirituality; Stress Management; Therapeutic Recreation; Mgt. (management) of mental illness." These interventions did not specify a time frame, frequency of attendance, or rationale for the interventions.

B. Policy Review

The policy titled: "Master Treatment Planning/Review Process," section #3 page 2 read: "Interventions are planned actions designed by staff to meet behavioral changes identified as goals. Interventions include the frequency and the discipline responsible for carrying out the intervention(s)."

C. Staff Interviews

1. In an interview on 7/11/11 at 1:10PM, RN 1 agreed that the interventions on the MTPs were a description of the discipline's job descriptions.

2. In an interview on 7/11/11 at 4:00PM, RN 2 was asked to define the modality listed on plans as "assess and involve in group therapy." Her response was that the patients attended all groups listed on the unit activity board. She concurred that the groups listed on the activity board were not listed as interventions on the patients' MTPs.

3. In an interview on 7/11/11 at 3:40PM with RN 3, she reported that the social worker came to the unit each morning with the list of groups the patients would attend that day. RN3 stated that the social worker printed the list from the physician's orders/clinical programming page because "we don't have time to get into that computer screen."

4. In an interview with the Medical Director 7/12/11 at 4:30PM, he concurred that specific group and/or individual interventions for each patient needed to be on the MTP.