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Based on record review, interview and policy review, the facility failed to provide Master Treatment Plans (MTP) that 1) specified interventions/modalities for 8 of 8 sample patients (P1, P2, P3, P4, P5, P6, P7 and P8) other than individual sessions and medication management, and 2) included psychiatrist and AT/OT (activity/occupational) therapist modalities for 6 of 8 sample patients (P2, P3, P4, P5, P6 and P7). The sample patients attended groups and activities that were posted; however, these groups were not listed on the treatment plans. These failures hamper staff's ability to provide direction and consistent approaches for patients' identified problems.
Findings include:

A. Record Review

1. Patient P1 was admitted on 7/12/10 with a diagnosis of "Schizoaffective disorder." The treatment plan (MTP) was dated 7/14/10. The intervention- "Nursing will meet a minimum of 3 times a week to discuss his symptoms of psychosis and provide education and support on symptom management" did not specify whether an individual or group session. There were no nursing groups listed on the plan.

2. Patient P2 was admitted on 6/22/10 with a diagnosis of "Schizophrenia." The MTP was dated 6/25/10. The intervention - "Nursing will assess for suicidal ideation (related to command hallucinations) each day" is a routine nursing function, not an individualized intervention. There were no AT/OT interventions.

3. Patient P3 was admitted on 7/9/10 with a diagnosis of "Bipolar Disorder." The MTP was dated 7/13/10. The Intervention "OT will meet with (patient) a minimum of twice weekly to explore healthy coping mechanisms he can utilize to better manage his mood to support his transition back to community living without utilizing negative means of coping such as chemical use." did not specify the modality There were no physician interventions.

4. Patient P4 was admitted on 7/15/10 with a diagnosis of "Mood disorder and polysubstance dependence." The MTP was dated 7/19/10. The Intervention "LPN/HST will encourage (patient) to attend 2 activities daily to help him decrease anxiety. (Enjoys cards, dice, Wii, fresh air)" Did not include the modality to be used. There were no activity/occupational therapist (AT/OT) or physician modalities/interventions listed on the treatment plan.

5. Patient P5 was admitted on 7/16/10 with a diagnosis of "Mood Disorder." The MTP was dated 7/20/10. The intervention "LPN/HST will encourage (patient) to attend a minimum of 2 activities daily to help him identify 3 ways he can reduce his anxiety through activities of his choice (Enjoys reading, Wii, cards, dice.)" had no specified modality. There were no AT/OT therapist or physician interventions on the treatment plan.

6. Patient P6 was admitted on 6/25/10 with a diagnosis of "schizophrenia." The MTP was dated 6/29/10. An intervention was "OT will meet with (patient) a minimum of twice weekly to assist him in identifying 2 ways in which developing a schedule will assist him in participating in group activities to ready him for discharge to placement setting." There was no specified modality. There were no physician interventions on the treatment plan.

7. Patient P7 was admitted on 6/5/10 with a diagnosis of "psychotic disorder due to traumatic brain injury." The MTP was dated 6/8/10. The intervention "HST/LPN will encourage (patient) in activities at least once daily to explore his interest to further engage him in conversations and provide positive feedback when behavior" had no specified modality. There were no AT/OT interventions on the plan.

8. Patient P8 was admitted on 6/30/10 with "depression, recurrent, with psychotic features." The MTP was dated 7/2/10. A nursing intervention was "RN will meet with (patient) a minimum of three times weekly to provide education on problem solving and developing coping skills so she can learn to better manage her stressors; pain, depression, and suicidal thoughts. Some coping skills education would be medication management, positive thinking, and alternative therapies for pain control, i.e.; heat massage, relaxation, importance of balance between rest and mild exercise, proper nutrition, and finding enjoyment in life." The modality (individual or group sessions) was not specified.

B. Policy Review

The facility document "Comprehensive Treatment Plan development and Reviews," dated March 2006, last revised September 2008, states "Intervention (Modalities): Actions that staff will take to assist the patient to accomplish his/her objectives. The interventions need to state the specific treatment modality [sic] used and the purpose, intent, or the impact the intervention is expected to have for the patient."

C. Staff Interviews

In an interview on 7/21/10 at approximately 11:00 AM, the Director of Nursing acknowledged that some of the treatment plans did not have physician or AT/OT interventions. She also added that treatment plan training and monitoring was the responsibility of the OTR (registered occupational therapist) who received the training in a state-wide treatment plan meeting.

Based on record review and staff interview, the names of physicians responsible for interventions were not specified for 5 of 8 active sample patients (P3, P4, P5, P6 and P8) and the names of AT/OT staff responsible for interventions were not specified for 3 of 8 active sample patients (P1, P2, and P7). Failure to identify the physicians and AT/ OT staff on treatment plans could result in physicians and AT/ OT staff being absent from patient care.

Findings include:

A. Record Review

1. Patient P1, a 25 year old man, admitted on 7/12/10 with a diagnosis of "schizoaffective disorder," had a treatment plan dated 7/14/10. His problem was listed as "psychotic decompensation." There were no names of AT/OT staff listed on the plan.

2. Patient P2, a 45 year old man, admitted on 6/22/10 with a diagnosis of "schizophrenia," had a treatment plan dated 6/25/10. His problem was listed as severe "suicidal ideations secondary to command auditory hallucinations." There were no names of AT/OT staff listed on the plan.

3. Patient P3, a 26 year old man, admitted on 7/9/10 with "bipolar disorder" and "polysubstance dependence (recent methamphetamine use)," had a treatment plan dated 7/13/10. His problem was listed as "lability of mood." There was no physician staff name listed on the plan, which could result in gaps in care.

4. Patient P4, a 45-year old man admitted on 7/15/10 with "mood disorder," "polysubstance dependence," and "back pain," had a treatment plan dated 7/19/10. His problem was listed as "depression." There was no physician name on the plan.

5. Patient P5, a 52 year old man admitted on 7/16/10 with "mood disorder NOS" and history of chest pain, had a treatment plan dated 7/20/10. His problem was listed as "depression." There was no physician name listed on the plan.

6. Patient P6, an 18 year old man admitted 6/25/10 with "schizophrenia" and "traumatic brain injury," had a treatment plan on 6/29/10. His problem was listed as "non-compliance." There was no physician name listed on the plan.

7. Patient P7, a 61 year old man admitted on 6/5/10 with a diagnosis of "psychotic disorder secondary to traumatic brain injury," had a treatment plan dated 6/8/10. His problem was listed "aggressive mood swings." There was no AT/OT staff names listed on the plan.

8. Patient P8 a 49 year old woman admitted 6/30/10 with "depression, fibromyalgia with severe hip and back pain, migraines," and "glaucoma," had a treatment plan dated 7/2/10. Her problem was listed as "depression." There was no physician name listed on the plan.

B. Policy Review

The facility's document, "Comprehensive Treatment Plan development and Reviews," dated March 2006, last revised September 2008, does not identify the specific disciplines comprising the treatment team. The document defines the team as: "Interdisciplinary Team - A group comprised of the patient, their family and supports, and clinicians working under the collaborative leadership of a clinician in integrated person centered treatment plan."

C. Staff Interview

In an interview with the Director of Nursing on 7/21/10 at approximately 11:00AM, the Director of Nursing acknowledged that some of the treatment plans did not include listed psychiatrist or AT/OT staff, She also added that treatment plan training and monitoring was the responsibility of the OTR (registered occupational therapist) who received the training in state-wide treatment plan training.

I. Based on record review and interview, the Clinical Director failed to assure the presence of: 1) specific interventions/modalities for eight of eight sample patients (P1, P2, P3, P4, P5, P6, P7 and P8) other than individual sessions and medication management, and 2) psychiatrist and AT/OT (activity/occupational) therapist modalities for six of eight patients (P2, P3, P4, P5, P6 and P7). The sample patients attended groups and activities that were posted; however, these were not listed on the treatment plans. These failures potentially results in staff being unable to provide direction and consistent approaches for patients' identified problems. (Refer to B122)

II. Based on record review and interview, the Clinical Director failed to assure the presence of the names of physicians responsible for interventions on the Master Treatment Plans of 5 of 8 active sample patients (P3, P4, P5, P6 and P8) and the names of AT/OT responsible for interventions for on the MTPs of 3 of 8 active sample patients (P1, P2, and P7). Failure to specify physician and AT/OT staff names potentially result in physician and AT/OT staff being absent from patient care. (Refer to B123)

III. Based on document review and interview, the Clinical Director failed to ensure that the facility followed through peer review for four of four medical staff (the Clinical Director, Primary Care Physician, and two APRNs). This deficient practice can result in failure to identify medical practices that negatively impact patient care.

Findings include:

A. Document Review

1. The CBHH "Medical Staff Performance Management Plan," revised 3/12/10, Section IV. Performance Measurement includes the following statement: "Performance Measurement is continuous with aggregation and trending completed on a quarterly basis."

2. Review of the "Quality of Care Case Review Summary" forms in the peer review folders of four of four medical staff (the Clinical Director, Primary Care Physician, and two APRNs) revealed no data for any quarter in 2009, and no data for the first quarter of 2010.

B. Staff Interview

1. In a telephone interview on July 22, 2010 at 2:45p.m., the Medical Director stated that while some data might be reviewed on a state-wide level, specific data for CBHH medical staff data was not reviewed quarterly. He acknowledged the facility was not following hospital policy.

2. In an interview on July 23, 2010 at 11:20a.m., the Hospital Administrator confirmed that there were no quarterly data available in the performance folders of the Clinical Director, the Primary Care Physician, or two APRNs for all of 2009, as well as none for the first quarter of 2010.