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Based on record review and interview, the facility failed to revise the treatment plans to include a treatment regime based on the current treatment needs for 2 of 8 active sample patients (C2 and D24) and 3 of 3 non-sample patients (B6, B22 and C37) who were added to the sample for review of active treatment. These patients were scheduled for groups that they failed to attend. In spite of continued refusals, treatment plans were not revised to meet patient needs. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, delaying their improvement.

Findings include:

A . Non-sample Patient B6 was admitted on 4/15/10 with a diagnosis of Schizophrenia Chronic, Undifferentiated Type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 1/13/13 with review date of 4/1/13, it stated "still refuses the medication at times...taking Lorazepam 2 mg at 8:00 AM, 1:00 p.m. and 9:00 p.m. for agitation...Prolixin 10 mg at 8:00 a.m., 1:00 p.m. and 9:00 p.m. for delusional thinking and Valproic acid 2000mg orally at bedtime for mood swings and aggression and 500 mg in the morning for aggression." The summary reported that s/he had been a victim of assault on 11/28/12 while in the hospital.

2. Based on the programming schedule (PSR) Patient B6 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13, Patient B6 had only attended one of his/her scheduled groups from 3/27/13 through 4/9/13. The participation note for this Medication Management group documented that Patient B6 was sleeping.

3. Interviews:

a. During interview with RN C1, RN C9 and SW C7 on 4/10/13 at 11:50 a.m., RNC9 reported that Patient B6 had been "decompensating." She stated that this patient would not get off the ward except to go to meals. RNC9 stated that the patient was "too sick to go to most groups."

b. During interview on 4/10/13 at 3:10 p.m., Health Care Technician (HCT) B14 reported that Patient B6 was "waiting to go home" and refused to attend groups.

4. Review of Patient B6's master treatment plan revision (1/9/13) with reviews (1/11/13, 2/1/13, 2/6/13, 4/1/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant in all areas of treatment. Patient B6's treatment team failed to develop a treatment regime based on his/her current behaviors.

B. Non-sample Patient B22 was admitted on 3/8/13 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 4/2/13, Patient B22 "continues to threaten the staff...continues to have persecutory delusions and thinks that people are out to harm [him/her]...[S/he] also has flashbacks of [his/her] childhood trauma where [s/he] was sexually abused as a child...[S/he] also has a history of alcohol use, marijuana and crack cocaine abuse."

2. Based on the programming schedule (PSR) Patient B22 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance notes provided by the staff on 4/10/13, Patient B22 had refused to attend all scheduled groups since admission. The only treatment other than on-going assessment by the psychiatrist was a 10-15 minute weekly session with the social worker.

3. Interviews:

a. During interview on 4/10/13 at 3:10 p.m., HCT B14 reported that Patient B22 refused to attend all groups and "stays in bed except to eat."

b. During interview on 4/10/13 at 4:00 p.m., RN B13 stated that Patient B22 refused to attend all treatment, stating "[S/he] only wants out of the hospital."

4. Review of Patient B22's master treatment plan (4/2/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant with the current plan. Patient B22's treatment team failed to develop a treatment regime based on his/her current behaviors.

C. Sample Patient C2 was admitted on 7/25/08 with diagnosis of schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 2/20/13 with review of 3/2/13, it stated "The intensity and frequency of the auditory or visual hallucinations have not changed since the decrease of the dose of Risperdal... [s/he] does not want to try a different medication..."

2. Review of Patient C2's group progress notes revealed that from 3/27/13 through 4/9/13 this patient refused to attend 19 of 19 (100%) scheduled groups (Anger Management, Task Skills and Medication Management). A psychiatrist progress note (3/26/13) documented, "[S/he] does not participate in therapeutic groups activities." A recreation therapy note (4/2/13) stated "...no programming attended this review [sic]." Based on a review of the record, the only documented treatment for this patient was reflected in a monthly social work progress note (3/12/13) that stated, "Supportive therapy on Monday 10-15 minutes at 2:15 pm with social worker."

3. Interviews:

During interview with Physician C12, RN C1 and SW (Social Worker) C9 on 4/10/13 at 11:35 a.m., Physician C12 reported that Patient C2 continued to refuse all treatment groups. He stated agreement that the treatment plan had not been changed and that even though a psychologist had worked with the patient in the past, there had been no recent psychological assessment of this patient about his/her continued refusal to engage in treatment other than medications. SW C9 stated, "We need to do something different with this patient."

4. Review of Patient C2's master treatment plan revision (2/20/13) with review (3/2/13) revealed no change in treatment schedule (groups and 1:1) as of 4/10/13, even though s/he was non-compliant in all areas of treatment other than medications. Patient C2's treatment team failed to develop a treatment regime based on his/her current behaviors.

D. Non-sample Patient C37 was admitted on 9/9/08 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of Patient B37's master treatment plan, revision dated 3/15/13, Pt. B37 was "less angry and hostile but continues to be so. It is agreed that this patient is still hallucinating most of the day...delusionses [sic] persist. [His/her] demeanor and attitude denote a severe paranoid feeling..."

2. Based on the programming schedule (PSR) Patient C37 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13, Patient C37 had only attended 2 of his/her scheduled groups for a brief period of time from 3/27/13 through 4/9/13.

3. Interviews:

During interview with RNC1, RN C9 and SWC7 on 4/10/13 at 11:50 a.m., RNC9 reported that Patient C37 "is decompensating. [S/he] won't get off ward except to go to meals." She added, "This patient is too sick to go to most groups. [S/he] is very psychotic."

4. Review of Patient C37's master treatment plan revision (3/15/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant with current treatment. Patient C37's treatment plan failed to develop a treatment regime based on his/her current behaviors.

E. Sample Patient D24 was admitted on 8/2/11 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

1. As documented in the summary and treatment section of the master treatment plan with most recent review date of 1/8/13, the patient, "who had been on NGRI (Not Guilty by Reason of Insanity) status, returned from ALS (Authorized Leave Status) contract for violation of smoking rules in the group home...During this review period [s/he] continues to be involved in smoking."

2. Group Progress notes for patient D24 in assigned Anger Management, Substance Abuse, and Group Psychotherapy modalities were reviewed. Progress notes for the assigned twice per week ADL Group were not provided. The notes provided showed attendance at 5 of 13 (38%) of assigned groups. The monthly psychiatric medication review note, monthly psychiatric progress note of 4/9/13 documented: "[S/he] continues having poor insight and poor motivation, as evidenced by needing several prompts to do [his/her] ADLs, taking medications, attending groups." The psychologist's group progress notes of 3/28/13, 4/4/13 and 4/9/13 all documented: "did not come when called." Social work group progress notes for 3/27/13, 3/29/13 and 4/1/13 documented: "Did not attend." The note from 4/3/13 documented: "did not attend-encouraged."

3. During an interview with the psychologist group leader on 4/9/13 he stated that the patient was, ironically, an active participant when s/he came to group but that there were no available options to motivate this patient to attend if s/he didn't want to attend.

4. Review of Patient D24's master treatment plan with most recent review 1/8/13, revealed no change in treatment schedule (groups and 1:1) as of 4/9/13, even though s/he was frequently non-compliant with group attendance. Patient D34's treatment team failed to develop a treatment regimen based on his/her current behaviors.

Based on record review and interview, the treatment plans included deficient goal statements for 7 of 8 active sample patients (B20, C8, C15, D24, D32, E13 and E19). Goals were stated in non-measurable terms that did not identify or delineate specific outcome behaviors for patients. In addition, some statements listed as goals for the patient to achieve were actually interventions staff would make. These deficiencies in goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record Review

1. Patient B20-Master Treatment Plan most current revision date of 2/13/13:

a. Problem #P1: "Psychosis as evidenced by responding to internal stimuli, delusional thinking, paranoid delusions and thinking that people are out to harm him and grandiose delusions..."

A short term goal was listed in non-measurable terms as "Patient will improve to the extent that [s/he] can function in the community in the supervised setting in the community without dangerousness. In next (sic) three months patient has (sic) decreased incidents of delusional thinking, grandiose delusions and responding to internal stimuli..."

a. Problem #P2: "Mood swing (sic) as evidenced by irritable mood, agitation, verbal aggression, physical aggression, pressured speech, screaming behavior, loud speech, argumentative behaviors, threatening behaviors."

A short term goal was listed in non-measurable terms as "...should have decreased incidents of physical aggression and decreased incidents of argumentative, hostile and verbal aggression." "Patient's mood will stabilize such that [s/he] maintains a normal level of activity, reasonably social, outgoing..."

b. Problem #PS1: "Poor social interaction skills as evidenced by being paranoid and suspicious, easily agitated/irritable, responding to internal stimuli, argumentative and delusional."

A short term goal was listed in non-measurable terms as "By 5/12/2013, patient will participate in AT/PSR group discussions in a relevant manner 25% of the sessions."

2. Patient C8-Master Treatment Plan dated 3/18/13 (no recent plan revision):

a. Problem #P1: "Chronic psychotic symptoms with disorganized thought, poor, insight, paranoid delusions, and poor compliance with medications. It also appears that family support is not that good..."

Statements on the plan were actually staff interventions, rather than short term goals that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will be continued on medications...[S/he] will be seen by me regularly, twice a week to see how [his/her] symptoms are improving." "The patient will be assigned to groups and will ask [him/her] to attend the groups at least two groups (sic)."

b. Problem #P2: "Substance Abuse Problem: [S/he] has been drinking alcohol almost every day. [S/he] says [his/her] preferred drink has been Grey Goose and smoking marijuana a regular basis along with his family members."

The statement on the plan was actually a staff intervention, rather than a short term goal that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will be continued to be educated about the importance of staying off from the drugs because it has a negative impact on [his/her] mental illness as well as [his/her] medications."

3. Patient C15-Initial Master Treatment Plan (1/10/13) with review (3/9/13). No treatment plan revision):

Problem #P1: "The patient with a long history of psychotic symptoms especially disorganized thinking and loose associations, tangential and disorganized at times. [His/her] speech has been incoherent, and paranoid delusions were present. [S/he] has been consistently getting angry and demanding things. [S/her] has been unable to live in a less restrictive environment and has poor judgment and impulse control problem."

A short term goal was stated in non-measureable terms as "In four weeks, the patient will have relevant conversation during therapy session twice a seek, and will start understanding [his/her] auditory hallucinations and delusions, showing some insight into them."

4. Patient D24-Master Treatment Plan dated 1/8/13:

a. Problem #P1: "The patient returned from NGRI status/ALS status for smoking in the group home and showing poor impulse control in [his/her] smoking behavior."

The statement on the plan was actually a staff intervention, rather than a short term goal that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient should attend three PSR groups, 45 minutes each, five days a week, able to discuss (sic) [his/her] problems with smoking and suggest the methods how to quit smoking to get out of this hospital, by April 08, 2013."

b. Problem #P2: "Illogical thinking disorganized thought process about smoking and about the dangerousness in the group home."

The statement on the plan was actually a staff intervention, rather than a short term goal related to the problem that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will attend at least three PSR groups, 45 minutes each, twice a day, five days a week, and able to show progress with good reality testing about [his/her] smoking problems and suggest ways to get rid of [his/her] smoking problem and how [s/he] remains smoking free when in the hospital and also after discharge into the community, by April 8, 2013 (sic)."

c. Problem #PS1: "Poor impulse control, as evidenced by poor judgment and smoking in unauthorized areas, also mood swings at times displaying slight agitation when redirected."

The statement on the plan was actually a staff intervention, rather than a short term goal related to the problem that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "By April 8, 2013, the patient will attend at least two groups each for 20 minutes."

5. Patient D32-Master Treatment Plan dated 2/8/13:

Problem #P3: "Lack of insight and judgement (sic) into her mental illness, need for continuing to take the medications, and substance abuse problems and the need to keep her out from the hospitals with ALS contract."

A short term goal was stated in non-measurable terms: "[S/he] will discuss the affects (sic) and side effects of the medications, the untoward effects of substance abuse and able (sic) to discuss the need to continue taking the medications, affects (sic) and side effects of the medications while in the hospital and also after discharge into the community by 05/08/2013."

6. Patient E13-Master Treatment Plan dated 3/27/13:

Problem #P1: "Aggressive behavior related to paranoid thinking and neglecting [his/her] basic care needs, including disheveled hair, long beard, unkept (sic) and interfered with [his/her] eating and [his/her] hygiene. [S/he] was also prompted to shower and put on clean clothing."

Short term goals were stated in non-measurable terms: "1. Cooperate with services focused on stabilizing the current acute psychotic episode. 2. Report a decrease in psychotic symptoms through the consistent use of psychotropic medications; 3. Identify the early warning signs and symptoms, exacerbation and decompensation. 4. Verbalize the acceptance of mental illness and to participate in the treatment recommended PSR groups and learn about mental illness."

7. Patient E19-Master Treatment Plan dated 4/3/2013:

a. Problem #P1: "Psychosis and also delusional behaviors..."

Short term goals were stated in non-measurable terms: "1. Cooperate with services focused on stabilizing the current acute psychotic episode. 2. Report a decrease in psychotic symptoms through the consistent use of psychotropic medications; 3. Identify the early warning signs and symptoms, exacerbation and decompensation. 4. Verbalize the acceptance of mental illness and to participate in the treatment recommended PSR groups and learn about mental illness."

b. Problem #P3: "Aggressive behavior..."

Short term goals were stated in non-measurable terms: "1) Comply with the medication evaluation to identify if medications will help abort the angry/assaultive outbursts. 2) Take medications as prescribed. 3) Attend all the recommended PSR groups and also discuss with the therapist about lack of aggressive behavior control and to learn about healthy alternative coping skills. 4) Learn to express feelings in a nonviolent manner."

c. Problem #PS1: "Impaired social skills..."

The statement on the plan was actually a staff intervention, rather than a short term goal related to the stated problem that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will improve socialization and attend at least one group per week as able with 1-2 prompts."

B. Interviews

a. An interview with review of treatment plan findings was conducted on 4/11/13 at 9:45 a.m. with the Chief of Medical Affairs, the Director of Nursing and the Director of Social Work. They agreed that many of the goals on the treatment plans were not measurable.

b. In an interview with the Chief of Medical Affairs on 4/11/13 at 9:00 a.m., he acknowledged that the short term goals for Patient D24 were confusing and written as interventions. In addition he acknowledged that correcting dictation errors was an ongoing problem which may contribute to the lack of clarity in Master Treatment Plan language.

Based on interview and document review, the Director of Nursing failed to meet the educational and/or on-going training requirements necessary for her administrative position as Executive Nurse within this facility.

Findings include:

A. At the time of this survey the Director of Nursing position was vacant; the person in the role was serving as Acting Director of Nursing.

B. Review of the Acting Director of Nursing's educational credentials revealed that she has an Associate Degree in Nursing.

C. Review of the credentials of the nursing consultant for the Department of Nursing revealed that she has a Masters in Health Administration, rather than Psychiatric Nursing. Additional review revealed e-mail messages reflecting a supportive relationship, rather than on-going documentation regarding the issues and problems related to the Department of Nursing and care provided to patients at this facility.

D. During interview on 4/11/13 at 9:15 a.m., the Acting Director of Nursing stated that she was aware that she does not have the educational qualifications required for the Director of Nursing position.