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Based on record review, staff interview and policy review, the facility identified identical generic short-term treatment goals for different patients with similarly identified problems on the treatment plans of 6 of the 7 sample patients (A5, A8, A9, A10, A13 and A16). This resulted in a document that failed to identify individualized expected treatment outcomes geared toward patient "need resolution" as described in policy.

Findings include:

A. Record Review

1. Goals regarding medication compliance

a. On the treatment plan for patient A5 dated 4/29/10, with updates 5/7/10, 5/13/10 and 5/18/10, the short-term goal #1 states A5 "agrees to medications as recommended, will report effects and side effects to staff daily."

b. On the treatment plan for patient A8 dated 5/11/10 and with update 5/18/10, the short-term goal #1 states A8 "agrees to medications as recommended, will report effects and side effects to staff daily."

c. On the treatment plan for patient A9 dated 5/20/10, the short-term goal #1 states A9 "agrees to medications as recommended, will report effects and side effects to staff daily."

d. On the treatment plan for patient A10 dated 2/22/10, with updates 3/4/10, 3/9/10, 3/16/10, 3/23/10, 3/30/10, 4/6/10, 4/14/10 and 4/21/10, the short-term goal #1 states A10 "agrees to medications as recommended, will report effects and side effects to staff daily."

e. On the treatment plan for patient A13 dated 4/16/10, with updates 4/21/10, 4/28/10, 5/5/10, 5/12/10 and 5/19/10, the short-term goal #1 states A13 "agrees to continue medications and report to MD and staff any improvements or complications."

f. On the treatment plan for patient A16 dated 5/19/10, the short-term goal #1 states A16 "agrees to take medications as prescribed reporting to MD and staff daily."

2. Goals regarding compliance with group attendance

a. On the treatment plan for patient A10 dated 2/22/10, with updates 3/4/10 and 3/9/10, the short-term goal #2 states A10 "will follow the unit routine and attend 2 groups daily to improve concentration and focus." On 3/16/10, 3/23/10, 3/30/10, 4/6/10, the only change to the short-term goal was to increase group frequency from 2 groups to 3 groups per day.

b. On the treatment plan for patient A16 dated 5/19/10, the short-term goal #2 states A16 "will agree to participate in the unit routine including 2 groups daily."

B. Staff Interview

1. In an interview on 5/20/10 at 2:00 p.m., when asked about specificity of goals and shown 2 sample treatment plans, the Medical Director stated "They are not specific enough; they sure are the same."

2. In an interview on 5/20/10 at 1:00 p.m. when asked about the individualization of goals and shown 2 sample treatment plans, the Director of Nursing said "I'm not surprised to see that they were generic."

C. Policy Review

1. On 5/20/10 at 2:45 p.m., the Director of Medical Records provided the policy titled "Treatment Planning" (SAC-IM-010), with revision date of 10/25/07. Page 3 of document describes short-term goals as objectives and qualifies them as follows:

a. "Objectives are expressed in measurable, behavioral terms and directed toward need resolution. Objectives can be seen, heard, etc. They are concrete."

b. "Objectives are statements of what the patient will be doing."

c. "Objectives are the steps to take to reach the goal."

2. On 5/20/10 at 2:30 p.m., the Director of Medical records provided the Medical/Professional Staff Organization Bylaws dated January 2008. Page 52, letter F. Treatment, item #34 states "Treatment planning begins on admission and is conducted in accordance with Dr. John C. Corrigan Mental Health Center protocol (IM O10.Doc)".

Based on record review, staff interview and policy review, the facility failed to develop treatment plans that identified individualized interventions to address specific patient problems. The interventions were routine, generic discipline functions inappropriately listed as individualized interventions for 5 of 7 sample patients (A1, A8, A9, A10 and A16), and failed to document patient progress or failure of progress for 5 of 7 sample patients (A1, A5, A8, A10 and A13). This deficient practice results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Psychiatrist Interventions

a. On the treatment plan for patient A1 dated 1/5/10, with updates 1/12/10, 1/19/10, 1/28/10, 2/2/10, 2/9/10, 2/17/10, 2/23/10, 3/4/10, 3/9/10, 3/16/10, 3/23/10, 3/30/10, 4/6/10, 4/13/10, 4/20/10, 4/27/10, 5/4/10, 5/11/10 and 5/18/10, the psychiatrist intervention states "MD2 will meet with A1 5x weekly to monitor mental status, prescribe medications, make changes as appropriate, monitor effects and side effects, provide education on her current treatment plan."

b. On treatment plan for patient A5 dated 4/29/10, with updates 5/7/10, 5/13/10 and 5/18/10, the psychiatrist intervention states "MD3 and MD4 will meet with A5 5x weekly to monitor mental status, prescribe medications, monitor response and side effects, monitor weekly CBC's, will schedule family meeting to discuss alternative treatment options including ECT."

c. On the treatment plan for patient A8 dated 5/11/10 and updated 5/18/10, the psychiatrist intervention states "MD1 will meet with A8 5x weekly to assess mental status, prescribe medications and monitor response."

d. On the treatment plan for patient A9 dated 5/20/10, the psychiatrist intervention states "MD1 will meet with A9 5x weekly to assess mental status, prescribe medications and monitor response and side effects, provide education about her condition and treatments."

e. On the treatment plan for patient A10 dated 2/22/10, with updates 3/4/10, 3/9/10, 3/16/10, 3/23/10, 3/30/10 and 4/6/10, the psychiatrist intervention states "MD1 will meet with A10 5x weekly to assess mental status, prescribe medications and monitor response and side effects, educate about her condition."

f. On the treatment plan for patient A13 dated 4/16/10, with updates 4/21/10, 4/28/10, 5/5/10, 5/12/10, and 5/19/10, the psychiatrist intervention states "MD2 will meet with A13 5x weekly to monitor mental status, prescribe medications, monitor response and provide education on his current treatment to improve insight, will work extended treatment team towards establishing an adequate discharge and aftercare plan, will also routinely discuss with A13 health practices including diet and exercise."

g. On the treatment plan for patient A16 dated 5/19/10, the psychiatrist intervention states "MD1, MD2, and MD3 will meet with A16 5xweekly, assess her mental status, encourage her to work with the treatment team to establish a treatment plan, including starting medication...Will work with the treatment team to establish a discharge plan."

2. Nursing Interventions

a. On the treatment plan for patient A1 dated 1/5/10, with updates 1/12/10, 1/19/10, 1/28/10, 2/2/10, 2/9/10, 2/17/10, 2/23/10, 3/4/10, 3/9/10, 3/16/10 and 3/23/10, the nursing intervention states "RN1 and staff will meet with A1 each shift to monitor safety and encourage her to discuss her feelings, provide hygiene supplies and encourage daily self care and provide assist as needed and administer medications as ordered." On 3/30/10, 4/6/10, 4/13/10, 4/20/10, 4/27/10, 5/4/10, 5/11/10 and 5/18/10, the staff name was changed from RN1 to RN2 but the intervention remained the same.

b. On the treatment plan for patient A5 dated 4/29/10, with updates 5/7/10, 5/13/10 and 5/18/10, the nursing intervention states "RN2 and staff will administer medications as ordered, provide education during Medication Education group and assess knowledge base. RN2 and staff will meet with A5 for at least 15 minutes every shift to encourage discussion of his feelings, will assist him in following the unit routine including attending meals, complying with lab work and attend select groups."

c. On the treatment plan for patient A8 dated 5/11/10, with update 5/18/10, the nursing intervention states "RN2 and staff will encourage A8 to discuss his feeling (sic) daily, provide a safe environment and assist as needed."

d. On the treatment plan for patient A10 dated 3/9/10, with updates 3/23/10, 3/30/10, 4/6/10 and 4/14/10, the nursing intervention states "RN2 and staff will meet with A10 each shift to encourage her to discuss her feelings, offer use of sensory room for relaxation, encourage attendance to groups as offered."

e. On the treatment plan for patient A13 dated 4/16/10, with updates 4/21/10, 4/28/10 and 5/5/10, the nursing intervention states "RN2 and staff will meet with A13 each shift to engage in reality based conversation, administer medications, provide medication education, assist with following the unit routine including daily hygiene."

3. Occupational Therapy Interventions

On the treatment plan for patient A1 dated 1/5/10, with updates 1/12/10, 1/19/10, 1/28/10, 2/2/10, 2/9/10, 2/17/10, 2/23/10, 3/4/10, 3/9/10 and 3/16/10, the occupational therapy intervention states "OT1 will meet with A1 to create an ADL schedule, encourage participation in Community Meeting, Snack Social and Expressive Therapy, monitor attention, concentration and socialization."

4. Social Work Interventions

a. On the treatment plan for patient A1 dated 2/2/10, with updates 2/9/10, 2/17/10, 2/23/10, 3/4/10 and 3/9/10, the social work intervention states "SW2 will work with A1 to communicate with family and supports and coordinate discharge."

b. On the treatment plan for patient A5 dated 4/29/10, with updates 5/7/10, 5/13/10 and 5/18/10, the social work intervention states "SW1 will work with A5 to arrange family meeting to discuss discharge options."

c. On the treatment plan for patient A13 dated 4/16/10, with updates 4/21/10, 4/28/10, 5/5/10, 5/12/10, and 5/19/10, the social work intervention states "SW3 will meet with A13 to work on building insight and judgment, encourage participation on the unit and coordinate transition back to partial hospital."

B. Staff Interview

1. In an interview on 5/20/10 at 2:00 p.m., the Medical Director concurred with the physician surveyor that the treatment interventions by the psychiatrist in the treatment plans were generic discipline functions and not individualized interventions to address specific patient problem. He said "Sure, they are not specific."

2. In an interview on 5/20/10 at 1:00 p.m., when asked about interventions and shown 2 sample treatment plans, the Director of Nursing said "I'm not surprised to see that they were generic."

3. In an interview on 5/20/10 at 11:00 a.m., when asked about interventions and shown 2 sample treatment plans, the Director of Social Work stated the quality "vary based on practitioner; some are more generic than others."

C. Policy Review

1. On 5/20/10 at 2:45 p.m. the Director of Medical Records provided the policy titled "Treatment planning" (SAC-IM-010), with revision date of 10/25/07. Page 3 under the Interventions section of the document describes the comprehensive treatment plan to contain:

a. Staff responsible for implementing portions of the plan
b. Anticipated time frames for completion
c. Frequency of treatment
d. Specific criteria to be met for termination of treatment
e. Specific services necessary to meet the patient's needs and includes referrals for services that are not provided directly by the facility
e. A specific plan for involving the family or significant others are included in the treatment plan when indicated.

2. On 5/20/10 at 2:30 p.m., the Director of Medical Records provided the Medical/Professional Staff Organization Bylaws dated January 2008. Page 52 letter F. Treatment, item #34 states "Treatment planning begins on admission and is conducted in accordance with Dr. John C. Corrigan Mental Health Center Protocol (IM O10.Doc)".

Based on record review, staff interview and policy review, the Medical Director failed to monitor and evaluate the quality and appropriateness of services and treatment provided by the medical staff. Specifically, the Medical Director failed to:

I. Ensure the treatment plans of 6 of 7 sample patients (A5, A8, A9, A10, A13, and A16) had their short-term goals individualized to their identified problems. This failure resulted in a document that failed to identify individualized expected treatment outcomes geared toward patient "need resolution" as described in the policy.

II. Ensure that psychiatrist interventions in the treatment plans of 5 of 7 sample patients (A1, A8, A9, A10 and A16) were individualized to address patient needs and were modified in successive treatment plans (updates) to demonstrate patient progress or lack of progress for 5 of 7 sample patients (A1, A5, A8, A10 and A13).

These deficiencies result in treatment plans that do no reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Lack of individualized short-term goals on treatment plans

a. On the treatment plan for patient A5 dated 4/29/10, with updates 5/7/10, 5/13/10 and 5/18/10, the short-term goal #1 states A5 "agrees to medications as recommended, will report effects and side effects to staff daily."

b. On the treatment plan for patient A8 dated 5/11/10 and with update 5/18/10, the short-term goal #1 states A8 "agrees to medications as recommended, will report effects and side effects to staff daily."

c. On the treatment plan for patient A9 dated 5/20/10, the short-term goal #1 states A9 "agrees to medications as recommended, will report effects and side effects to staff daily."

d. On the treatment plan for patient A10 dated 2/22/10, with updates 3/4/10, 3/9/10, 3/16/10, 3/23/10, 3/30/10, 4/6/10, 4/14/10 and 4/21/10, the short-term goal #1 states A10 "agrees to medications as recommended, will report effects and side effects to staff daily."

e. On the treatment plan for patient A13 dated 4/16/10, with updates 4/21/10, 4/28/10, 5/5/10, 5/12/10 and 5/19/10, the short-term goal #1 states A13 "agrees to continue medications and report to MD and staff any improvements or complications."

f. On the treatment plan for patient A16 dated 5/19/10, the short-term goal #1 states A16 "agrees to take medications as prescribed reporting to MD and staff daily."

2. Lack of individualized psychiatrist interventions

a. On the treatment plan for patient A1 dated 1/5/10, with updates 1/12/10, 1/19/10, 1/28/10, 2/2/10, 2/9/10, 2/17/10, 2/23/10, 3/4/10, 3/9/10, 3/16/10, 3/23/10, 3/30/10, 4/6/10, 4/13/10, 4/20/10, 4/27/10, 5/4/10, 5/11/10 and 5/18/10, the psychiatrist intervention states "MD2 will meet with A1 5x weekly to monitor mental status, prescribe medications, make changes as appropriate, monitor effects and side effects, provide education on her current treatment plan."

b. On the treatment plan for patient A5 dated 4/29/10, with updates 5/7/10, 5/13/10 and 5/18/10, the psychiatrist intervention states "MD3 and MD4 will meet with A5 5x weekly to monitor mental status, prescribe medications, monitor response and side effects, monitor weekly CBC's, will schedule family meeting to discuss alternative treatment options including ECT."

c. On the treatment plan for patient A8 dated 5/11/10, with update 5/18/10, the psychiatrist intervention states "MD1 will meet with A8 5x weekly to assess mental status, prescribe medications and monitor response."

d. On the treatment plan for patient A9 dated 5/20/10, the psychiatrist intervention states "MD1 will meet with A9 5x weekly to assess mental status, prescribe medications and monitor response and side effects, provide education about her condition and treatments."

e. On the treatment plan for patient A10 dated 2/22/10, with updates 3/4/10, 3/9/10, 3/16/10, 3/23/10, 3/30/10 and 4/6/10, the psychiatrist intervention states "MD1 will meet with A10 5x weekly to assess mental status, prescribe medications and monitor response and side effects, educate about her condition."

f. On the treatment plan for patient A13 dated 4/16/10, with updates 4/21/10, 4/28/10, 5/5/10, 5/12/10 and 5/19/10, the psychiatrist intervention states "MD2 will meet with A13 5x weekly to monitor mental status, prescribe medications, monitor response and provide education on his current treatment to improve insight, will work extended treatment team towards establishing an adequate discharge and aftercare plan, will also routinely discuss with A13 health practices including diet and exercise."

g. On the treatment plan for patient A16 dated 5/19/10, the psychiatrist intervention states "MD1, MD2, and MD3 will meet with A16 5x weekly, assess her mental status, encourage her to work with the treatment team to establish a treatment plan, including starting medication. Will work with the treatment team to establish a discharge plan."

B. Staff Interview

1. In an interview on 5/20/10 at 2:00 p.m., when asked to comment about specificity of goals and shown sample treatment plans of patients A5 and A13, the Medical Director concurred with the physician surveyor that the short term treatment goals were quite generic and "sure looked the same."

2. In an interview on 5/20/10 at 2:00 p.m., the Medical Director concurred with the physician surveyor that the treatment interventions by the psychiatrist in the treatment plans were generic discipline functions and not individualized to address specific patient problems. He said "they sure are not specific."

C. Policy Review

1. On 5/20/10 at 2:45 p.m., the Director of Medical Records provided the policy titled "Treatment Planning" (SAC-IM-010), with revision date of 10/25/07. Page 3 of document describes short-term goals as objectives and qualifies them as follows:

a. "Objectives are expressed in measurable, behavioral terms and directed toward need resolution. Objectives can be seen, heard, etc. They are concrete."

b. "Objectives are statements of what the patient will be doing."

c. "Objectives are the steps to take to reach the goal."

2. On 5/20/10 at 2:45 p.m., the Director of Medical Records provided the policy titled "Treatment Planning" (SAC-IM-010), with revision date of 10/25/07. Page 3 under the Interventions section of the document describes the comprehensive treatment plan to contain:

a. Staff responsible for implementing portions of the plan
b. Anticipated time frames for completion
c. Frequency of treatment
d. Specific criteria to be met for termination of treatment
e. Specific services necessary to meet the patient's needs and includes referrals for services that are not provided directly by the facility
f. A specific plan for involving the family or significant others are included in the treatment plan when indicated.

3. On 5/20/10 at 2:30 p.m., the Director of Medical Records provided the Medical/ Professional Staff Organization Bylaws dated January 2008. Page 52 letter F. Treatment, item #34 states "Treatment planning begins on admission and is conducted in accordance with Dr. John C. Corrigan Mental Health Center Protocol (IM O10.Doc)".

Based on record review, staff interview and policy review, the Director of Nursing failed to monitor and evaluate the quality and appropriateness of documentations on the treatment plans by the nursing staff. Specifically, the Director of Nursing failed to:

I. Assure that Registered Nurses documented individualized goals for 2 of 7 sample patients (A10 and A16).

II. Assure that nursing interventions were patient specific and not generic functions of the discipline for 5 of 7 patients (A1, A5, A8, A10 and A13) and that the interventions were modified to demonstrate patient progress or lack of progress for 5 of 7 sample patients (A1, A5, A8, A10, A13).

This deficiency results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Failure to assure that RNs documented individualized patient goals

a. On the treatment plan for patient A10 dated 2/22/10, with updates 3/4/10 and 3/9/10, the short-term goal #2 states A10 "will follow the unit routine and attend 2 groups daily to improve concentration and focus." On 3/16/10, 3/23/10, 3/30/10, 4/6/10, the only change to the short-term goal was to increase group frequency from 2 groups to 3 groups per day.

b. On the treatment plan for patient A16 dated 5/19/10, the short-term goal #2 states A16 "will agree to participate in the unit routine including 2 groups daily."

2. Failure to assure the nursing interventions were individualized and modified

a. On the treatment plan for patient A1 dated, 1/5/10, with updates 1/12/10, 1/19/10, 1/28/10, 2/2/10, 2/9/10, 2/17/10, 2/23/10, 3/4/10, 3/9/10, 3/16/10 and 3/23/10, the nursing intervention states "RN1 and staff will meet with A1 each shift to monitor safety and encourage her to discuss her feelings, provide hygiene supplies and encourage daily self care and provide assist as needed and administer medications as ordered." On 3/30/10, 4/6/10, 4/13/10, 4/20/10, 4/27/10, 5/4/10, 5/11/10 and 5/18/10, the staff name was changed from RN1 to RN2 but the intervention remained the same.

b. On the treatment plan for patient A5 dated 4/29/10, with updates 5/7/10, 5/13/10 and 5/18/10, the nursing intervention states "RN2 and staff will administer medications as ordered, provide education during Medication Education group and assess knowledge base. RN2 and staff will meet with A5 for at least 15 minutes every shift to encourage discussion of his feelings, will assist him in following the unit routine including attending meals, complying with lab work and attend select groups."

c. On the treatment plan for patient A8 dated 5/11/10, with update 5/18/10, the nursing intervention states "RN2 and staff will encourage A8 to discuss his feeling (sic) daily, provide a safe environment and assist as needed."

d. On the treatment plan for patient A10 dated 3/9/10, with updates 3/23/10, 3/30/10, 4/6/10 and 4/14/10, the nursing intervention states "RN2 and staff will meet with A10 each shift to encourage her to discuss her feelings, offer use of sensory room for relaxation, encourage attendance to groups as offered."

e. On the treatment plan for patient A13 dated 4/16/10, with updates 4/21/10, 4/28/10 and 5/5/10, the nursing intervention states "RN2 and staff will meet with A13 each shift to engage in reality based conversation, administer medications, provide medication education, assist with following the unit routine including daily hygiene."

B. Staff Interview

In an interview on 5/20/10 at 1:00 p.m., when asked about individualization of treatment goals and interventions and shown 2 sample treatment plans, the Director of Nursing said "I'm not surprised to see that they were generic." She said "they no longer used a checklist," and that the "staff tend to fall back on familiar language when typing treatment plans." She agreed that the nursing interventions were generic and were discipline specific functions and not individualized to meet patient specific needs.

C. Policy Review

1. On 5/20/10 at 2:45 p.m., the Director of Medical Records provided the policy titled "Treatment Planning" (SAC-IM-010), with revision date of 10/25/07. Page 3 of document describes short-term goals as objectives and qualifies them as follows:

a. "Objectives are expressed in measurable, behavioral terms and directed toward need resolution. Objectives can be seen, heard, etc. They are concrete."

b. "Objectives are statements of what the patient will be doing."

c. "Objectives are the steps to take to reach the goal."

2. On 5/20/10 at 2:45 p.m., the Director of Medical Records provided the policy titled "Treatment Planning" (SAC-IM-010), with revision date of 10/25/07. Page 3 under the Interventions section of the document describes the comprehensive treatment plan to contain:

a. Staff responsible for implementing portions of the plan
b. Anticipated time frames for completion
c. Frequency of treatment
d. Specific criteria to be met for termination of treatment
e. Specific services necessary to meet the patient's needs and includes referrals for services that are not provided directly by the facility
f. A specific plan for involving the family or significant others are included in the treatment plan when indicated.

3. On 5/20/10 at 2:30 p.m., the Director of Medical Records provided the Medical/Professional Staff Organization Bylaws dated January 2008. Page 52 letter F. Treatment, item #34 states "Treatment planning begins on admission and is conducted in accordance with Dr. John C. Corrigan Mental Health Center Protocol (IM O10.Doc)."