HospitalInspections.org

Based on Policy Review, Record Review and Staff Interviews, the Facility failed to develop Master Treatment Plans (MTPs) that included long term goals which were stated in measureable behavioral terms for 4 of 8 active sample patients (A1, A8, A9, and A13). This deficient practice hampers the ability of the treatment team to measure change in the patient and may contribute to failure of the team to modify plans in response to patient needs, as well as contributing to patient stays beyond the resolution of the behavior requiring admission.

Findings include:


A. Policy Review

Facility policy TX-GEN-02, titled "Treatment Planning: Integrated/multidisciplinary", dated September 2006, stated "The treatment plans includes defined" --- "measurable goals" --- " based on assessed needs."


B. Record Review

1. Patient A1. Non-measureable long term goals on the MTP dated 8/8/11 were:
"Pt [patient] will experience an overall improvement in behaviors & [and] moods."
"Pt will experience overall improvement in socialization skills."

2. Patient A8. Non-measurable long term goals on the MTP dated 8/9/11 were:
"Pt will have improvement in mood."
"Pt will experience overall improvement in mood & thought process."

3. Patient A9. Non-measurable long term goal on the MTP dated 8/12/11 was:
"Pt will experience improved mood & thought process with ability to tolerate environment/stimuli."

4. Patient A13. Non-measurable long term goals on the MTP dated 8/8/11 were:
"Pt will experience an overall improvement in reality orientation in socialization."
"Pt will experience an overall improvement in reality orientation with decreased confusion and improved functioning."


C. Staff Interviews

1. In an interview on 8/16/11 at 9:55a.m., the non-measurable long term goals were discussed with the Medical Director. He did agree with the findings.

2. In an interview on 8/16/11 at 11:50a.m., the non-measurable long term goals were discussed with the Nursing Director who shared responsibility with the Social Work Director in monitoring the quality of the treatment plans. She agreed with the findings.

Based on Record Review and Staff Interview, the Facility failed to ensure that the name of the Attending Physician responsible for addressing the mental health issues of his/her patient was listed next to each psychiatrist intervention on the Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A1, A5, A7,A9, A13, A16, and A17). This practice resulted in the facility's inability to monitor this staff's accountability for specific treatment modalities.

Findings include:


A. Record Review

Review of the following Master Treatment plans (dates of the plans in parenthesis) did not include the name of the psychiatrist responsible for the physician interventions related to mental health issues: patient A1 (8/8/11), A5 (8/8/11), A7 (8/6/11), A9 (8/12/11), A13 (8/5/11), A16 (8/12/11), and A17 (8/12/11).


B. Staff Interview

In an interview on 8/16/11 at 9:55a.m., the lack of physician names and signatures on the physician interventions related to mental health issues was discussed with the Medical Director. He agreed that the responsible physicians' names should be on the Master Treatment Plans.

Based on Policy Review, Record Review and Staff Interviews, the Medical Director failed to adequately ensure the quality and appropriateness of services provided by the clinical staff. Specifically the Medical Director failed to:

I. Ensure that Master Treatment Plans included long term goals which were stated in measureable behavioral terms for 4 of 8 active sample patients (A1, A8, A9, and A13). This deficient practice hampers the ability of the treatment team to measure change in the patient and may contribute to failure of the team to modify plans in response to patient needs. This practice also may contribute to patient stays beyond the resolution of the behavior requiring admission. (Refer to B121.)

Findings include:


A. Policy Review

Facility policy TX-GEN-02, titled "Treatment Planning: Integrated/multidisciplinary", dated September 2006, stated "The treatment plans includes defined" --- "measurable goals" --- " based on assessed needs."


B. Record Review

1. Patient A1. Non-measureable long term goals on the MTP dated 8/8/11 were:
"Pt [patient] will experience an overall improvement in behaviors & [and] moods."
"Pt will experience overall improvement in socialization skills."

2. Patient A8. Non-measurable long term goals on the MTP dated 8/9/11 were:
"Pt will have improvement in mood."
"Pt will experience overall improvement in mood & thought process."

3. Patient A9. Non-measurable long term goal on the MTP dated 8/12/11 was:
"Pt will experience improved mood & thought process with ability to tolerate environment/stimuli."

4. Patient A13. Non-measurable long term goals on the MTP dated 8/8/11 were:
"Pt will experience an overall improvement in reality orientation in socialization."
"Pt will experience an overall improvement in reality orientation with decreased confusion and improved functioning."


C. Staff Interviews

In an interview on 8/16/11 at 9:55a.m., the non-measurable long term goals were discussed with the Medical Director. He did agree with the findings.


II. Ensure that the name of the Attending Physician responsible for addressing the mental health issues of his/her patient was listed next to that psychiatrist's intervention on the Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A1, A5, A7, A9, A13, A16, and A17). This practice resulted in the facility's inability to monitor this staff's accountability for specific treatment modalities. (Refer to B123)

Findings include:

A. Record Review

Review of the following Master Treatment plans (dates of the plans in parenthesis) did not include the name of the psychiatrist responsible for the physician interventions related to mental health issues: patient A1 (8/8/11), A5 (8/8/11), A7 (8/6/11), A9 (8/12/11), A13 (8/5/11), A16 (8/12/11), and A17 (8/12/11).

B. Staff Interviews

In an interview on 8/16/11 at 9:55a.m., the lack of physician names and signatures on the physician interventions related to mental health issues was discussed with the Medical Director. He agreed that the responsible physicians' names should be on the Master Treatment Plans.