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Based on record review and interviews, the Master Treatment Plans (called "treatment plans" by the facility) of 11 of 13 active sample patients (A10, B2, B9, D6, D17, E1, E10, F12, F18, G6 and H4) failed to document a focus and/or purpose of group interventions that correlated with identified patient problems and treatment objectives. Instead, group interventions were either listed on the treatment plan with no stated focus and/or purpose, or a list of group interventions were attached to the treatment plan. This attachment provided a description of the groups that were identical for each patient assigned to groups. The groups on the attachments contained no stated focus and/or purpose that were based on the individual needs of each patient. This failure potentially hinders the treatment team's ability to provide and evaluate treatment based on the patient's presenting needs and behaviors.

Findings are:

A. Record Review:

Patient A10

The patient's Treatment Plan Part II dated 2/25/10 noted under the section "Rehabilitation Staff Section (Specify):" "At present, [A10] is scheduled for the following groups, programs and activities: Admission Group Therapy; A.M. and P.M. Daily Goal-Setting and Goal-Review Groups; Leisure Skill Development; Move It!; Smoking Cessation/Fire Safety; Anger Management; Assertive Communication; Making Leisure Choices; Understanding the Emotions you Experience; Community Awareness; Music Therapy; Motor Skills Training through Games; Relaxation Techniques; Medication Management; Community Meeting; You & Your Physician; A Healthier You; The Road to Recovery; Body Sculpting; Social/Leisure Skills Practice; Stress Management; Coping Strategies; Speak Up; Living Well; P.M. Strozzi Education; and Illness Management and Recovery. [A10]'s individual schedule and program descriptions are attached."
The rest of the Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups that were based on the patients' presenting problems or needs.

Patient B2

The patient's treatment plan dated 2/4/10 included an attachment that included the following assigned groups with a group description: "Goals Group (Scheduled AM and PM); Community; Resources & Skill Building; Daytime Fitness Walk; Wellness Self-Management; Swim/Water Exercise; Stress Management Through walking; Cultural Awareness; Positive Attitude; Fitness Walk - Evening; Community Exploration/Social Clubs; Swimming for Health; Stress Management; (P) Personal Wellness; Fitness Walk - Evening; Staying Well (NB); Walking for Health; Cooking Techniques and Sanitation; Community Meeting - Ward 67; Motor Skill Training Through Games; Self Determination (7 North); Goal Setting; Basic Safety Skills; Goal Setting; Psycho-Social Re-integration; Gym Activity/Weight Training; You and Your Physician; BPC Moment; Symptom Management - Weekend."

The rest of the Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

Patient B9

The patient's treatment plan dated 1/26/10 included an attachment that included the following assigned groups with a group description: "Goals Group (Scheduled AM and PM); Community Resources & Skill Building; Learning Life Skills; Freedom of Speech; Recovery; Resource Management; Positive Attitudes; Physical Awareness Through Exercise; Hobby Group; Cognitive Behavioral Therapy; Money Management; Increased Social Awareness; Homemaking Skills; Creative Expression Through Music; Music Therapy (Evenings); Healthy Living; Transportation Training; BPC Medication Update; Mental Health Awareness & Relapse Prevention; Nutrition; Using Humor in your Day; BPC Moment".


The rest of the Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

Patient D6

The patient's Treatment Plan Part II dated 2/9/10 noted under the section "Rehabilitation Services" "At present, [D6] is scheduled for the following programs: Expressive Arts; A Healthier You; Move It!; Strozzi Education; Daily A.M. Goal-Setting; Daily P.M. Goal-Review Groups; Medication Management; Music Therapy; Social/Leisure Skills Practice; Relaxation Techniques; Speak Up; Stress Management Skills; Making Leisure Choices; Coping Skills; Illness Management and Recovery; Community Meeting; You & Your Physician; Motor Skill Training Through Games; Body Sculpting; Smoking Cessation; Admission Group Therapy; and Co-Occurring Disorders. [D6]'s individual schedule and program descriptions are attached."

The rest of the Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

Patient D17

The patient's Treatment Plan Part II dated 2/10/10 noted under the section "Rehabilitation Services": "At present, [D17] is scheduled for the following Admission Unit programs: Making Leisure Choices; Daily Goal-Setting and Goal-Review groups; Women's Issues; Peer Group; Discharge Planning; Move It!; Expressive Arts; Speak Up; Cognitive Behavioral Strategies; Community Meeting; Smoking Cessation; Co-Occurring Disorders; Leisure Skill Development; You & Your Physician; Coping Skills; Assertive Communication; and Anger Management."

The rest of the Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

Patient E1

The patient's Treatment Plan dated 12/15/09 included an attachment that included the following assigned groups with a group description: "Goals Group (Scheduled AM and PM); Social/Leisure Practice: Varied Activities & Games; Recovery Skills; Social/Leisure Skills Practice: Special Events; Creative Studio; Morning Wake-up; Getting Needs met; Relationships and boundaries; Afternoon Rap-up; Women Issues; Social/Leisure Skills: Karaoke; Community Music; Spirituality; Leisure Exploration; Creative Expression Through Music; Coping With Stress; Relaxation Techniques; Relationships for Survivors; Wellness/Self Management; Brain Games; Money Management; Discharge Strategies; Social/Leisure Skills Practice: Self-Help - R.A.M.'s [Recipient Associate Manager]; Fresh Air/Fitness; Cooking; Community Meeting; Building Social Support; You and Your Physician; Social/Leisure Skills Practice: Bingo; A-Holistic Wellness; Social Effectiveness; Life Issues; BPC Moment; Community Resources & Skill Building; Symptom Management; Social/Leisure Skills Practive [sic]: A Dance."

The rest of the Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

Patient E10

The patient's Treatment Plan dated 1/5/10 included an attachment that included the following assigned groups with a group description: "Goals Group (Scheduled AM and PM); Recovery Skills; Social/Leisure Skills Practice: Special Events; Creative Studio; Morning Wake-up; Education; Afternoon Rap-up; Simple Mediations & Easy Relaxation Exercises; F - Social/Leisure Skills: Karaoke; Community Music; Spirituality; Healthy Living; Leisure Exploration; Coping with Stress; Relaxation Techniques; Medication Management; Yoga & Relaxation Techniques; Money Management; Music Therapy; Social/Leisure Skills Practice: Self-Help - R.A.M.'s [Recipient Associate Manager]; Creative Studio; Cooking; Community Meeting; CBT [Cognitive Behavioral Therapy]; You and Your Physician; Social/Leisure Skills Practice: Bingo; Fresh Air/Fitness; Wii-Creation; Expressing my Faith - Art Therapy; Life Issues; Social/Leisure Skills Practice: Varied Activities & Games; Social Skills Practice in the Environment; BPC Moment; Community Resources & Skill Building; Symptom Management; Social/Leisure Skills Practive [sic]: A Dance."

The rest of the Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

Patient F12

The patient's Treatment Plan dated 2/3/10 included an attachment that included the following assigned groups with a group description: "Goals Group (Scheduled AM and PM); Recovery Skills; Social/Leisure Skills Practice: Varied Activities & Games; Social/Leisure Skills Practice: Special Events; Education; Beyond BPC [Buffalo Psychiatric Center]; Value Exploration; Music Therapy; Body Sculpting; Community Music; Individualized Activities; Healthy Living; Community Resources; You and Your Physician; The Creative Studio; Budgeting; Building Social Skills (Shaping); Surviving Trauma; Current Events; Express Yourself; Relaxation Techniques; Community Resources & Skill Building; Social/Leisure Skills Practice; Social/Leisure Skills Practive [sic]: A Dance."

The rest of the Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

Patient F18

The patient's Treatment Plan dated 1/17/10 included an attachment that included the following assigned groups with a group description: "Environmental Awareness Group; Goals Group (Scheduled AM and PM); Health Maintenance; Community Integration; Recovery Skills; Social/Leisure Skills Practice: Special Events; Education; Skill Development; Rehab Education; Social/Leisure Skills: Karaoke; News Currents; Social Skills with Your Physician; Getting Motivated; Social/Leisure Skills Practice: Self-Help - R.A.M.'s [Recipient Associate Manager]; Spirituality; Relaxation Techniques; Creative Writing; Fresh Air/Fitness; Money Management; Community Meeting; Community Resources & Skill Building; Social/Leisure Skills Practice: Varied Activities & Games; Symptom Management; BPC [Buffalo Psychiatric Center]; Social/Leisure Skills Practive [sic]: A Dance."

The Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

Patient G6

The patient's Treatment Plan dated 1/21/10 included an attachment that included the following assigned groups with a group description: "Goals Group (Scheduled AM and PM); Health Maintenance; Recovery Skills; Social/Leisure Practice: Varied Activities & Games; Social/Leisure Skills Practice: Special Events; Walk away the Pounds; Freedom of Speech; Recreation & the Community; Communication Skills; Coping with Stress; Social/Leisure Skills: Karaoke; Understanding Mental Illness and It's [sic] Treatment; Physical Awareness Through Exercise; Music Therapy; Recreation Skills; Community Resources; Getting Your Needs Met in the Mental Health System; Walking for Health; Money Management; Community Meeting; You and Your Physician; Social/Leisure Skills Practice: Self-Help - R.A.M.'s [Recipient Associate Manager]; Current Events; Medication Management; Community Reintegration; Surviving Trauma; Social/Leisure Skills Practice: Bingo; Ball Stability-Aerobic; Double Trouble; Skills for Success; Handling Emotions; Relaxation Techniques; Symptom Management; BPC [Buffalo Psychiatric Center]; Community Resources & Skill building; Social/Leisure Skills Practive [sic]."

The Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

Patient H4

The patient's Treatment Plan Part II, dated 11/27/09 and due to be revised 3/16/10, included an attachment that included the following assigned groups with a group description: "Goals Group (Scheduled AM and PM); F - Social/ Leisure Skills Practice: Varied Activities & Games; Recovery Skills; A - Creative Studio 2N; Mind and Body Connection Tai Chi; A-Community Music - 2N; Schizophrenia Anonymous; A-Leisure Exploration; Motor skill Training Through Games; Social /Leisure Skills Practice: Bingo; Medication Management; Healthy Lifestyles; Managing your Emotions; Interpersonal Skills; Symptom Management; BPC Moment."

The Treatment Plan and attachments did not identify a specific focus and/or purpose for any of the groups based on the patient's presenting problems or needs.

B. Policy Review

A review of the "Uniform Case Record, New York State Department of Mental Health, Instructions for Part II Form 278 BPC (Goal Plan Methods) IV. Procedure" revealed the following statements: "A) Enter method(s) (interventions) per discipline for each objective in the appropriate discipline column. Methods-treatment interventions which will be utilized to assist the patient in the attainment of goals and objectives. Methods should describe what staff is actually doing with an emphasis on individualized approached [sic]."

C. Interview

The surveyors interviewed the Director of Quality Improvement and the Unit 67 Treatment Team Leader on 3/9/10 at 3:15 P.M. Both staff persons were shown the list of interventions on the treatment plan and/or the attached list of groups for the active sample. The Unit 67 Treatment Team Leader stated "There's a need to tighten the connection between groups and treatment objectives on the treatment plan." The Director of Quality Improvement agreed with this statement.

Based on record review and interviews, the facility failed to insure adequate documentation by not addressing identified problems and topic(s) discussed during the groups in the treatment notes of 12 of 13 active sample patients (A2, A10, B2, B9, D6, D17, E1, E10, F12, F18, G6 and H4) and two active non-sample patients (G1 & G10). The treatment notes (Treatment Service Report - TSR) contained custodial documentations relative to the patient's attendance in activities rather than clinical notations of the patient's response related to the problems and treatment goals on the treatment plan. This failure potentially hinders the treatment team from determining the patient's response to treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings are:

A. Record Review:

A review of the "Treatment Service Reports" [TSR] revealed the following treatment notes did not contain specific topics discussed during group sessions or show that the discussion was related to the patient's problems identified on the treatment plan.

1. Sample Patients

Patient A2:

Group Activity: "Dealing with Difficult Situations"; Date: 1/11/10; Comment: Attended for one hour but no comment noted.

Group Activity: "Stress Reduction"; Date: 2/5/10; Comment: "participated."

Group Activity: "Symptom Management - Weekend (Dr." [sic]; Date: 1/9/10; Comment: Attended 0.75 hour but no comment noted.

Group Activity: "Symptom Management - Weekend (Dr." [sic]; Date: 2/6/10; Comment: Attended 0.75 hour but no comment noted.

Patient A10

Group Activity: "Goals Group"; Date: 1/23/10; Comment: Attended group for 0.5 hour but no comment noted.

Group Activity: "Peer Group"; Date: 1/27/10; Comment: Attended for one hour but no comment noted.

Group Activity: "Goals Group - On Unit 72"; Date: 1/30/10; Comment: Attended group for 0.5 hour, but no comment noted.

Group Activity: "Understanding the Emotions You"; Date: 2/9/10; Comment: Attended the group for one hour, but no comment noted.

Patient B2

Group Activity: "Symptom Management - Weekend (Dr." [sic]; Date: 1/23/10; Comment: "program in the basement."

Group Activity: "Symptom Management - Weekend (Dr." [sic]; Date: 2/6/10; Comment: Attended group for 0.75 hour but no comment noted.

Group Activity: "Goals Group"; Date: 2/22/10; Comment: "went to program."

Group Activity: "Stress Management"; Date: 1/19/10; Comment: "attentive."

Patient B9

Group Activity: "Symptom Management - Weekend (Dr." [sic]; Date: 1/16/10; Comment: Attended group for 0.75 but no comment noted.

Group Activity: "Cognitive Behavioral Therapy"; Date: 2/3/10; Comment: Attended 0.75 hour but no comment noted.

Group Activity: "Relaxation Techniques"; Date: 2/16/10; Comment: Attended 0.75 hour but no comment noted.

Group Activity: "Understanding Mental Illness and It's... [sic]"; Date: 2/2/10; Comment: Attended 0.70 hour but no comment noted.

Patient D6

Group Activity: "Peer Group"; Date: 1/6/10; Comment: Attended group for one hour but no comment noted.

Group Activity: "Anger Management"; Date: 1/11/10; Comment: Attended group for one hour but no comment noted.

Group Activity: "Coping Skills"; Date: 2/14/10; Comment: Attended group for 0.75 hour but no comment noted.

Patient D17

Group Activity: "Cognitive Behavioral Strategies"; Date: 2/12/10; Comment: Attended group for one hour but no comment noted.

Group Activity: "Women's Group"; Date: 2/17/10; Comment: Attended group for one hour but no comment noted.

Group Activity: "Relaxation Techniques"; Date: 2/25/10; Comment: Attended group for 0.75 hour but no comment noted.

Patient E1

Group Activity: "Life Issues"; Date: 2/5/10; Comment: "participated."

Group Activity: "CBT" (Cognitive Behavior Therapy); Date: 2/25/10; Comment: "active."

Group Activity: "Symptom Management"; Date: 1/23/10; Comment: "cooperative."

Group Activity: "Goal Group (Evening) - Unit 75"; Date: 2/10/10; Comment: "keep on going to group."

Patient E10

Group Activity: "Life Issues"; Date: 1/15/10; Comment: "ok."

Group Activity: "Building Social Support"; Date: 1/28/10; Comment: "ok."

Group Activity: "Relationship for Survivors"; Date: 2/3/10; Comment: "active."

Group Activity: "Strong Women"; Date: 2/22/10; Comment: "participates."

Patient F12

Group Activity: "Anger Management"; Date: 1/4/10; Comment: Attended group for one hour but no comment noted.

Group Activity: "Building Social Skills (Shaping)"; Date: 2/18/10; Comment: "participated."

Group Activity: "Goals Group (Evening) - Unit 76"; Date: 2/2/10; Comment: Attended group for 0.75 hour but no comment noted.

Group Activity: "Relaxation Techniques"; Date: 2/12/10; Comment: Attended group for 0.75 hour but no comment noted.

Patient F18

Group Activity: "Handling Emotions"; Date: 1/15/10; Comment: "attentive and shared when asked."

Group Activity: "Building Social Skills (Shaping)"; Date: 1/21/10; Comment "participated, name not on schedule."

Group Activity: "Living with Respect"; Date: 1/28/10; Comment: "quiet but attentive."

Group Activity: "Life Management"; Date: 1/29/10; Comment: "slept prompts to wake ineffective."

Group Activity: "Handling Emotions"; Date: 2/5/10; Comment: "quiet but able to share when it was his turn."

Group Activity: "Skills for Success"; Date: 2/5/10; Comment: "observing others and environment, alert, attending."

Patient G6

Group Activity: "Symptom Management - Weekend (Dr. [sic]"; Date: 1/9/10; Comment: Attended group for 0.75 hour but no comment noted.

Group Activity: "Symptom Management"; Date: 1/16/10; Comment: Attended group for 0.75 hour but no comment noted.

Group Activity: "Goals Group - On Unit 77"; Date: 1/7/10; Comment: "active."

Group Activity: "Goals Group"; Date: 1/20/10; Comment: "ok."

Patient H4

Group Activity: "Schizophrenia Anonymous"; Date: 2/23/10; Comment: attended group 0.75 hours but no comment noted.

Group Activity: "Symptom Management - Weekend (Dr. [sic]"; Date: 1/23/10; Comment: "accipts [sic] suggestions."

Group Activity: "Interpersonal Skills"; Date: 2/11/10/; Comment: Attended group 0.75 hours but no comment noted.

Group Activity: "Relaxation Techniques"; Date: 2/11/10; Comment: Attended group 0.75 hours but no comment noted.

Non-Sample Patients

Patient G1

Group Activity: "Cultural Diversity"; Date: 2/4/10; Comment: "restless wandering."

Group Activity: "Shaping the Mind"; Date: 2/19/10; Comment: "excited."

Group Activity: "Goals Group (Evening) - Unit 77"; Date: 1/12/10; Comment: "tx [treatment] compliance."

Group Activity: "Symptom Management - Weekend (Dr. [sic]"; Date: 1/16/10; Comment: Attended group for 0.75 hours but no comment noted.

Patient G10

Group Activity: "Healthy Living"; Date: 2/16/10; Comment: "participated."

Group Activity: "Symptom Management - Weekend (Dr. [sic]"; Date: 1/16/10; Comment: Attended group for 0.75 hours but no comment noted.

Group Activity: "Symptom Management - Weekend (Dr. [sic]"; Date: 2/6/10; Comment: Attended group for 0.75 hours but no comment noted.

Group Activity: "Goals Group"; Date: 1/20/10; Comment: "appropriate."

B. Interviews:

1. On 3/9/10 at 9:15 a.m., during rounds with the Medical Director on Unit 65, the surveyor inquired about the schedule of the psychiatrist who does weekend group activities, especially doing eight (8) groups on Saturdays. The Medical Director responded "She hasn't been getting her notes done for those groups" (referring to the TRS Forms).

2. On 3/9/10 on Unit 72 at 9:45 a.m., the Medical Director pointed out that "the TTL's (Treatment Team Leaders) complete the TRS because the doctor don't [sic] have enough time to finish them." He agreed that the TSR Forms did not address the specific problems of each patient.

3. 0n 3/9/10 at 4:20 p.m., the surveyor reviewed the treatment plans and the TSR reports of the active sample patients attending the Medication Management Group. The group leader acknowledged that the TSR report did not specify what topics were discussed.

4. On 3/10/10 at 9:45 a.m., the surveyor reviewed the TSR reports with the Director of Quality Improvement. She [Director of QI] agreed that the TSR did not identify any specific patient problems or progress other than noting patient's level of participation.