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Based on medical record review, and staff interview it was determined that for six (6) of eight (8) patients the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion. This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapeutic endeavors. (Patients A2, A4, B1, B2, B3, and B4).

Findings include-----

A. Medical Record Review:

1. Patient A2: The Psychiatric Evaluation dated 5/17/2013 stated as the patient's assets to be used in therapy, "Patient is able to communicate [his/her] needs and issues." "Patient has reached the 11th grade" and "Patient has a work history."

2. Patient A4: The Psychiatric Evaluation dated 7/12/2013 stated as the patient's assets, "Articulates well" and "Agrees to treatment."

3. Patient B1: the Psychiatric Evaluation dated 3/19/2013 stated as the patient's assets, "Advocates for [himself/herself]" and "Has supportive family-but limited availability."

4. Patient B2: The Psychiatric Evaluation dated 2/07/2014 stated, "Good family support" and "Able to express [his/her] needs and advocate for [himself/ herself]."

5. Patient B3: The Psychiatric Evaluation dated 10/02/2013 stated as the patient's assets "Able to make [his/ her] needs known" and "Reportedly worked as a police woman for 13 years."

6. Patient B4: The Psychiatric Evaluation dated 12/04/2013 stated "Articulates well" as the sole asset.

B. Staff Interview:


On 4/15/2014 the Clinical Director was interviewed. The Director was shown the findings described in Section I above. He agreed that the statements did not reflect an assessment of individualized patient assets in a descriptive and non interpretive manner.

Based on record review and staff interviews, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on the Master Treatment Plans (MTPs) for seven (7) of eight (8) active sample patients (A1, A3, A4, B1, B2, B3, and B4). Problem statements which had to be resolved, eliminated and/or reduced prior to discharge were not based on each patient's presenting behaviors. Instead, the stated problems on MTPs included diagnostic terms and/or evaluative statements regarding symptoms. This failure results in MTPs that are not comprehensive or individualized to how patients evidenced presenting psychiatric problems.

Findings include:

A. Record review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (4/3/14), A2 (updated (3/3/14), A3 (updated 3/17/14), A4 (updated 3/27/14), B1 (3/25/14), B2 (updated 3/14/14), B3 (updated 4/3/14), and B4 (updated 3/10/14). This review revealed that the MTPs had the following problem statements that had no supporting documentation to reflect how presenting symptoms were individually manifested for each patient in descriptive and behavioral terms.

1. Patient A1 was admitted 3/27/14 with a diagnosis of "Schizophrenia Undifferentiated Type"; The psychiatric problems listed on the MTP were: "Problem 1: Poor medication and treatment compliance"; "Problem 2: Poor nutritional intake"; "Problem 3: Religious preoccupations"; "Problem 4: Hallucinations and selective mutism"; There was no content included in the psychiatric problem statements that clearly outlined behavioral descriptions of how the patient manifested the psychiatric symptoms identified or how the patient manifested non-compliance with medication and treatment, such as not being able to obtain medications (transportation and/or financial problems), stopped taking medications because of side effects, lack of knowledge, etc.

2. Patient A3 was 7/19/13 with a diagnosis of "Schizoaffective Disorder"; The psychiatric problems listed on the MTP were: "Problem1: History of medication non-compliance;" "Problem 2: History [sic] violent and aggressive behavior"; "Problem 5: Poor insight around mental illness"; There was no content included in the psychiatric problem statements that clearly outlined behavioral descriptions of how the patient manifested the psychiatric symptoms identified or how the patient manifested non-compliance with medication.

3. Patient A4 was admitted 7/8/13 with a diagnosis of "Psychotic Disorder NOS [Not Otherwise Specified]"; The psychiatric problems listed on the MTP were: "Problem 1: Disorganized thoughts"; "Problem 2: Delusional and tangential speech"; "Problem 5: Mood Disorder w [with]/history of aggressive behavior"; There was no content included in the psychiatric problem statements that clearly outlined behavioral descriptions of how the patient manifested the psychiatric symptoms and diagnostic terms identified.

4. Patient B1 was admitted 3/17/14 with a diagnosis of "Schizoaffective Disorder." The psychiatric problems listed on the MTP were: "Problem 1: [Patient's name] is currently evidencing psychosis manifested by disorganized thinking, bizarre and often aggressive behavior, auditory hallucinations, poor insight poor judgment,..." "Problem 2: History of non-compliance with treatment." There was no content included in the psychiatric problem statements that clearly outlined the evident statement using behavioral descriptions of how the patient manifested the psychiatric symptoms identified (e.g. grandiosity and paranoid beliefs) or how the patient manifested non-compliance with treatment.

5. Patient B2 was admitted 2/7/11 with a diagnosis of "Schizoaffective Disorder". The psychiatric problems listed on the MTP were: "Problem 1: Poor impulse Control; Low Frustration Tolerance, Grandiosity and/or paranoid beliefs..."; "Problem 2: [Patient's name] displays threatening, aggressive behaviors"; "Problem 3: History of suicidal attempts/gestures and self-injurious behaviors." There was no content included in the psychiatric problem statements that clearly outlined behavioral descriptions of how the patient manifested the psychiatric symptoms identified or how the patient manifested non-compliance with treatment.

6. Patient B3 was admitted 9/13/12 with a diagnosis of "Schizoaffective Disorder". The psychiatric problems listed on the MTP were: "Problem 1: Hx [History] of noncompliance with medications." "Problem 2: Hx [History] of anxiety and suicidal ideation." There was no content included in the psychiatric problem statements that clearly outlined behavioral descriptions of how the patient manifested the psychiatric symptoms identified or how the patient manifested non-compliance with medications.

7. Patient B4 was admitted 12/4/13 with a diagnosis of "Schizophrenia Disorganized Type." The psychiatric problems listed on the MTP were: "Problem 1: Disorganization, confusion, Thought blocking"; "Problem 2: Non-compliance with medication regime". There was no content included in the psychiatric problem statements that clearly outlined behavioral descriptions of how the patient manifested the psychiatric symptoms identified or how the patient manifested non-compliance with medication regime.

B. Interviews

1. During interview on 4/14/14 at 3:15 p.m. with RN1, the problem statements on the MTPs were discussed. RN1 acknowledged that problem statements were not individualized and did not include behaviorally descriptions of patients presenting symptoms.

2. During interview on 4/15/14 at 1:45 p.m. with the Utilization Review (UR) Coordinator, the MTPs were discussion. The UR Coordinator acknowledged that problems statements on the MTPs did not describe how patients manifested the symptoms and/or diagnostic terms identified.

Based on document review and interview, the facility failed to provide Master Treatment Plans (MTPs) that specified the names of staff responsible for interventions. Specifically, for three (3) of eight (8) active sample patients (A3, A4, and B2), the MTPs failed to identify the responsible persons for the assigned interventions on the MTPs. Failure to assign specific staff members as responsible for implementing the chosen treatment interventions results in an inability to determine what staff member is responsible for ensuring the interventions are implemented and for staff accountability, thus, potentially hampering the effective coordination of treatment modalities.

Findings include-----

I. Document Review:

A. The facility's "Uniform Case Record Policy and Procedure Manual" in the Section titled "COMPREHENSIVE TREATMENT AND RECOVERY PLAN-KPC-431 MED" states in Section V. INSTRUCTIONS A. All treatment team members are expected to be present for the Comprehensive Treatment and Recovery Plan meeting." And further in Section F. "The names of all members present at the treatment planning meeting shall be recorded. The plan must be signed by the staff member responsible for writing it up..." Section D.4.(c) states, "The name and title of the staff member who will provide the treatment intervention ( name may be omitted if the intervention will be provided by multiple staff members)." This instruction does not follow the Standard which states that the ultimate responsible staff person must be identified.

B. Treatment Plan Review:

1. Patient A3: The Treatment Plan dated (11/05/2013) lacked the signature of a nurse as having been present and assuming the responsibility for the following interventions assigned to that discipline - "nursing staff will meet with (Patient A3) in the Psych education group 3x per week for 45-55 min to help improve awareness of reasons for adhering to prescribed medication regime both as an inpatient and outpatient and to help improve insight into illness" and "Nursing staff will meet with (Patient A3) in the Lifestyle Balance group 1x per week for 55 min to help him learn to use stress management strategies (e.g. smoking cessation, getting adequate rest & sleep, modification of alcohol consumption, etc.). "

2. Patient A4: The Treatment Plan dated (3/27/2014) lacked the signature of a nurse as the responsible staff member for that discipline. However, the following treatment modalities or interventions had been assigned : "Nursing staff will meet with (Patient A4) in the Psych Education group 2x per week for 45-55 min to help improve ability to verbalize importance of continued treatment and to help improve insight into illness", and "Nursing staff will monitor weight and vital signs monthly. Nursing staff will provide ongoing education and reinforce need for compliance with prescribed medical recommendations to assure good health."

3. Patient B2-The Treatment Plan dated 2/11/2014 had only the initials of the team Social Worker as having been present and formulating discipline specific interventions. Lacking was evidence that the psychiatrist, the responsible nurse, the dietician, the "Rec(Recreational) Therapist", the "Treatment Team Ld M H" (Lead Mental Health), and the Psychology Extern were involved in treatment planning.

II. Staff Interview:

The surveyors discussed the findings noted in Section I above with the facility's Quality Assurance Director on 4/16/2014 at 9:45 a.m.. The expectation of the facility as stated in their Policy for Treatment Team attendance as well as the need to clearly assign a staff member as responsible when interventions by nursing staff members and recreational staff members may extend for a considerable period of time and be delivered by various staff within that discipline was discussed. The Quality Assurance Director agreed that clarification and compliance were indicated, and responds, "Yes, our policy needs to be reviewed".

Based on observation, record review, and interview, the facility failed to ensure that all interventions [called methods by the facility] listed on the Master Treatment Plans (MTPs) were documented by the assigned clinical staff for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, for several interventions identified on MTPs, there was no documentation showing patients' attendance or non-attendance in group sessions; the topic(s) discussed; and/or patients' level of response to the treatment interventions provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

Findings include:

A. Observation

During observation on 4/15/14 from 9:45 a.m. to 10:47 a.m., Patient A3 who was admitted 7/19/13 was in a group entitled "Symptom Management" conducted by Psychiatrist1. The patient was very drowsy, kept his head down during most of the meeting, and participated only when asked to respond to a request by Psychiatrist1. During discussion after the group session on 4/15/14 at 10:53 a.m., with Psychiatrist1 and Treatment Team Coordinator1, Patient A3's medical record was reviewed to locate treatment notes written regarding the patient's attendance and non-attendance in the symptom management group. Psychiatrist1 admitted that there were no treatment notes written about the patient's participation or non-attendance in the symptom management group. Treatment plan coordinator1 noted that each group leader was responsible for documenting the patient's attendance and his/her response to the intervention after each group session. Treatment team coordinator 1 also stated that group leaders were supposed to include a summary of group sessions in the patient's progress notes. Psychiatrist1 admitted that symptom management group sessions were not summarized in Patient A3's medical record.

B. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (4/3/14), A2 (updated (3/3/14), A3 (updated 3/17/14), A4 (updated 3/27/14), B1 (3/25/14), B2 (updated3/14/14), B3 (updated 4/3/14), and B4 (updated 3/10/14). The weekly and monthly progress notes recorded during the periods of February 2014 through March 2014 and April 14, 2014 through April 15, 2014 were reviewed. According to facility staff, these progress notes were also used to record treatment notes. These notes revealed that there were no treatment notes or insufficient information documented for interventions delivered by the following clinical disciplines.

1. Psychiatrist Interventions:

For Patients A1, A3, A4, B2, B3, and B4 - "Symptom Management with [Psychiatrist's name] 55 min [minutes] /wk [week]..."

For Patients A2, A3, A4, B2, and B4 - "Psychiatrist will meet with [Patient's name] in the Understanding Your Illness group 1x/wk for 55 min [minutes]..." [Some of the intervention statements were identical or similarly worded.]

Notes written by psychiatrists on the progress note forms were primarily regarding patients' mental status, medications, and progress. Group treatment notes were not mentioned at all in most of the progress notes and if mentioned, recorded a general statement about groups. There were no group treatment notes by psychiatrists for the patients above that recorded: (1) the number of groups attended or not attended, (2) information provided or topic discussed during the group session(s), and (3) the patients' responses, including the patient's behavior during group sessions, level of participation and/or level of understanding.

2. Registered Nurse (RN) Interventions:

For Patients A1, A2, A3, B1, B2, B3, and B4 - "Psycho education 2x [times] /wk [week] with RN..."

For Patient A2 - "MEDSAP [Medication Education] 1/wk with RN..."

For Patients A1, A3, B1, B2, B3, and B4 - "Life balance group 1x/wk with RN for 55 min [minutes]..."

Notes written by RNs were primarily progress and event notes. Under "Patient Teaching" section of the "Nurse's Weekly/Monthly Progress Note" Form, notes written by RNs contained the names of groups and "Instruction/Teaching Done & Method" which documented whether intervention(s) involved doing a demonstration, giving verbal information, and/or providing handout(s). However, there were no group treatment notes by registered nurses for the patients above that recorded: (1) the number of groups attended or not attended, (2) information provided or topic discussed during the group session(s), and (3) the patients' responses, including the patient's behavior during group sessions, level of participation and/or level of understanding.

3. Social Work (SW) Interventions:

For Patients A1 and A4 - "Coping with addiction group 1x [time] /wk [week] for 55 min [minutes] with SW... "

For Patients A2 - "Mental Health Recovery weekly for 55 min [minutes with [Social Worker's name]..." "Independent Living Skills weekly for 55 min [minutes]..."

For A3, A4, and B3 - "Social Worker will meet with [Patient's name] in the Conflict Resolution group 1x per week for 55 min [minutes]..."

For A3 and A4 - "Social Worker will meet in the Community Re-integration group 1x per week for 55 min..."

For A4 and B3 - "Social Worker will meet with [Patient's name] 1x per week for 45 min..."

For B2 - "Social Skills, Creative Expression and, Interpersonal Skills groups with [Social Worker's name], SW..."

For B3 - "Social Worker will meet with [Patient's name] in the Communication skills Group 1x per week for 55 min [minutes]..."

Notes written by social workers on the progress note forms were primarily progress notes and included only a general statement regarding groups attended by patients. There were no group treatment notes by social workers for the patients above that recorded: (1) the number of groups attended or not attended, (2) information provided or topic discussed during the group session(s), and (3) the patients' responses, including the patient ' s behavior during group sessions, level of participation and/or level of understanding.

4. Rehabilitation Therapy Interventions:

For Patients A1 and B3 - "Leisure activities group 1x [time] /wk [week]..."

For Patients A1, A2, B2, and B4 - "Cognitive skills enhancement 55 min [minutes] with rehab [rehabilitation] staff..."

For A1and B3 - "Relaxation /Stress management group with Rec [Recreational] Therapist 1x/wk..."

For A2 and A4 - "Grooming Skills for 55 minutes with [Patient's name]..."

For A3 and B3 - "Rec/Rehab [Recreational/Rehabilitation] staff will meet with [Patient's name] in the Social Skills group 1x per week for 55 min [minutes]..."

For A3 - "Rec/Rehab [Recreational/Rehabilitation] staff will meet with [Patient's name] in the Adaptive Coping Skills group 1x per week for 55 min [minutes]... "

For A3 and A4 - "Rec/Rehab [Recreational/Rehabilitation] staff will meet with [Patient's name] in the Adaptive Coping Skills group 1x per week for 55 min [minutes]..."

For A3 and B3 - "Rec/Rehab [Recreational/Rehabilitation] staff will meet with [Patient's name] in the Building Interpersonal Skills group 1x per week for 55 min [minutes]..."

For A3 and B4 - "Rec/Rehab [Recreational/Rehabilitation] staff will meet with [Patient's name] in the Creative Expression group 1x per week for 55 min [minutes]..."

Notes written by the rehabilitation therapy staff recorded the number groups attended for only three (3) of the seven (7) progress note forms provided. Most of the notes recorded patients' responses to group treatment but failed to provide a summary of the topics or focus of group activities during the group sessions attended by patients.

C. Interviews

1. During interview on 4/14/14 at 3:15 p.m. with RN1, the documentation of treatment notes for interventions assigned on the MTPs was discussed. RN1 stated, "Treatment Mall notes are done after each group by the group leader for each patient attending and entered in the computer [on the Treatment Mall Group Data Sheet."] RN1 acknowledged that these computerized sheets were not included in patients' medical records.

2. During interview on 4/15/14 at 11:50 a.m. with the Director of Rehabilitation Therapy (RT), the documentation of treatment notes assigned to rehabilitation staff for Patient A3 was discussed. The Director of RT acknowledged that the topics or focus of the group sessions that the patient attended were not recorded. She stated, "These are not very good" and noted that the surveyor should see better treatment notes recorded by other RT staff.

3. During interview on 4/15/14 at 1:45 p.m. with the Utilization Review (UR) Coordinator, treatment notes for interventions assigned on the MTP were discussion. The UR Coordinator confirmed that notes recorded on the progress notes form did not include adequate information about the number of groups attended or not attended or patients' response to group treatment.

Based on record review and interview, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to ensure that all nursing interventions [called methods by the facility] listed on the Master Treatment Plans (MTPs) were documented by the assigned clinical staff for seven (7) of eight (8) active sample patients (A1, A2, A3, B1, B2, B3, and B4). Specifically, for the registered nurse group interventions identified on MTPs, there was no documentation showing patients' attendance or non-attendance in group sessions; the topic(s) discussed during group sessions; and/or adequate information regarding the patients' level of response to the treatment interventions provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

Findings include:

A. Record Review

Nursing Interventions:
For Patients A1, A2, A3, B1, B2, B3, and B4 - "Psycho education 2x [times] /wk [week] with RN..."

For Patients A2 - "MEDSAP [Medication Education] 1/wk with RN..."

For Patients A1, A3, B1, B2, B3, and B4 - "Life balance group1x/wk with RN for 55 min [minutes]..."

Notes written by RNs were primarily progress and event notes. Under "Patient Teaching" section of the "Nurse's Weekly/Monthly Progress Note" Form, notes written by RNs contained the names of groups and "Instruction/Teaching Done & Method" which documented whether intervention(s) involved doing a demonstration, giving verbal information, and/or providing handout(s). However, there were no group treatment notes by registered nurses for the patients above that recorded: (1) the number of groups attended or not attended, (2) information provided or topic discussed during the group session(s), and (3) the patients' responses, including the patient's behavior during group sessions, level of participation and/or level of understanding.

B. Interview

During interview on 4/15/14 at 3:55 p.m. with the Director of Nursing (DON), treatment notes for interventions assigned to registered nurses were discussed. The DON stated, "The documentation is not adequate."