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Based on record review and interview, the facility failed to ensure that the Psychosocial Assessments included individualized recommendations for social work services from the data gathered for six (6) of eight (8) active sample patients (A9, A12, A13, A16, A23 and A25). As a result, specific social work recommendations regarding treatment of patient's psychosocial problems were not described for the treatment team.

Findings include:

A. Record Review

1. Patient A5 was admitted on 9/7/15. The Psychosocial Assessment, no date and signing, stated under "Assessed Needs for Treatment": "Pt [patient] to meet 1:1 [one to one] daily x[times]7 [with] psychiatrist, 1:1 3[three] x [with] c.c. [clinical counselor - also known as social worker at this facility] & [and] attend minimum of 1 [one] clinical group daily x7."
There was no mention of the specific role of the social worker in treatment and discharge planning for this patient.

2. Patient A12 was admitted on 9/9/15. The Psychosocial Assessment, dated 9/9/15, stated under "Assessed Needs for Treatment": "Gather [illegible word], individual therapy, psychiatry, TA Therapeutic Activity] gps [groups], milieu gp. [group], teach pt. healthy coping skills, ¿ [increase] supports."

There was no mention of the specific role of the social worker in treatment and discharge planning for this patient.

3. Patient A13 was admitted on 8/25/15. The Psychosocial Assessment, dated 8/26/15, stated under "Assessed Needs for Treatment": "[Name of patient] will meet c.c. 3x weekly and prn [as needed] for individual counseling, will attend groups and meet with psychiatrist daily, will be re-linked to BPC [name of local state hospital] OP [outpatient] clinic.

There was no mention of the focus or purpose of re-linking the patient to the state hospital or which discipline would be doing the referral."

4. Patient A16 was admitted on 9/8/15. The Psychosocial Assessment, dated 9/8/15, stated under "Assessed Needs for Treatment": "Pt to meet 1:1 3x7 with c.c., 1:1 daily [with] psychiatrist, & attend minimum 1[one] clinical group daily."

There was no mention of the specific role of the social worker in treatment and discharge planning.

5. Patient A23 was admitted on 9/2/15. The Psychosocial Assessment, dated 9/3/15, stated under "Assessed Needs for Treatment " : "Pt to meet 1:1 daily x7 [with] c.c., 1:1 daily x7 [with] psychiatrist, & to attend minimum of 1 clinical group daily x7."

There was no mention of the specific role of the social worker in treatment and discharge planning.

6. Patient A25 was admitted on 8/31/15. The psychosocial Assessment, dated 9/1/15, stated under "Assessed Needs for Treatment": "[Name of patient] will meet [with] c.c. 3x weekly and prn for individual counseling, will attend groups and meet [with] psychiatrist daily, will be re-linked to [name of nurse practitioner] at Brylin OP and linked to OP counselor."

There was no mention of the specific role of the social worker in treatment and discharge planning.


B. Interview

In an interview on 9/15/15 at 8:33 a.m., the lack of including the specific individualized social work role on the Psychosocial Assessments was discussed with the Director of Social Work. He stated, "The things you are asking about are in the Progress Notes, but I'll talk to the staff about including them (social work roles) in the Psychosocial Assessments too."

Based on record review and interview, the facility failed to ensure that Psychiatric Evaluations included an inventory of specific patient assets that could be used in treatment planning for five (5) of eight (8) active sample patients (A12, A13, A16, A23 and A25). The failure to identify patient assets can impair the treatment team's ability to develop treatment interventions utilizing the individual strengths of each patient.

Findings include:

A. Record Review

None of the following Psychiatric Evaluations included patient assets (dates of evaluations in parenthesis): A12 (9/11/15), A13 (8/27/15), A16 (9/10/15), A23 (9/4/15) and A25 (9/2/15).


B. Interview

In an interview on 9/15/15 at 9:45 a.m., the lack of assets on the Psychiatric Evaluation was discussed with the Medical Director failed. She stated, "We're going to transition into an EMR [Electronic Medical Record] system soon and programs will allow us to include assets. People get in a pattern of dictating and just forget all they should include."

Based on record review, policy review and interviews, the facility failed to provide treatment plans that identified specific, measurable short term goals based on the individualized patient needs for eight (8) of eight (8) sample patients, (A9, A12, A13, A16, A23, A25, B1 and B4). This failure hinders the ability of the team to measure changes in the patient and may lead to fragmentation of care.

Findings:

A. Record Review

1. Patient A9 (Treatment Plan dated 9/9/15) had the identified problem, "Depression, anxiety, altered mental status" and the short term goal, "Patient will remain free from harm and demonstrate decreased depression and SI [suicidal ideation] within 7 days."

This short term goal is not measurable or specific to the patient.

2. Patient A12 (Treatment Plan dated 9/10/15) had the identified problem, "Altered mental status" and the short term goal, "Pt [patient] will remain safe during hospital stay thru D/C [discharge]."

This short term goal is not measurable or specific to the patient.

3. Patient A13 (Treatment Plan dated 8/25/15) had the identified problem, "depressed" and the short term goal, "[Patient's] impulses to harm self will diminish while hospitalized for 7-10 days."

This short term goal is not measurable or specific to the patient.

4. Patient A16 (Treatment Plan dated 9/8/15) had the identified problem, "Depression, anxiety [with] panic" and the short term goal, "Pt [patient] will remain free from harm and demonstrate decreased SI [suicidal ideation] and anxiety within 7 days."

This short term goal is not measurable or specific to the patient.

5. Patient A23 (Treatment Plan dated 9/2/15) had the identified problem, "Depression" and the short term goal, "Pt [patient] to report [decreased] depression, [no] SI [suicidal ideation], [increased] ADLs [activities of daily living], [decreased] impulsivity x 7."

This short term goal is not measurable or specific to the patient.

6. Patient A25 (Treatment Plan dated 9/1/15) had the identified problem, "Safety, Mood Instability" and the short term goal, "[Patient] will exhibit an [increase] in mood stability and report [no] suicidal thoughts within 5-7 days."

This short term goal is not measurable or specific to the patient.

7. Patient B1 (Treatment Plan dated 9/9/15) had the identified problem, "Alteration in coping pattern, verbalized thoughts of suicide" and the short term goal, "Increase desire to live."

This short term goal is not measurable or specific to the patient.

8. Patient B4 (Treatment Plan dated 9/1/15) had the identified problem, "Aggressive behavior" and the short term goal, "Pt. [patient] will maintain safety for next 72 [hours]."

This short term goal is not measurable or specific to the patient.


B. Policy Review

The facility policy PCS-1.10 titled "Multidisciplinary Treatment Plan" (revised 6/14) states, "A comprehensive individualized treatment plan is developed for each patient by the multidisciplinary treatment team within 24-48 hours of admission." In addition, it states, "The comprehensive treatment plan is strength based and includes identified patient strengths and short term goals."


C. Interviews

1. On 9/15/15 at 9:10 a.m. MD1 stated, "I see what you mean. It would be hard to measure the short term goals the way that they are written."

2. On 9/15/15 at 9:15 a.m. the Clinical Director stated, "I agree. The goals are not individualized or measurable."

Based on record review, policy review and interviews the facility failed to develop specific physician and nursing psychiatric interventions based on the assessed needs for eight (8) of eight (8) sample patients (A9, A12, A13, A16, A23, A25, B1 and B4). This deficiency results in a failure to guide treatment staff to achieve measurable behavioral outcomes.

Findings:

A. Record Review

1. Patient A9, T.P. (Treatment Plan) dated 9/9/15, had the following interventions for the short term goal, "Patient will remain free from harm and demonstrate decreased depression and SI [suicidal ideation] within 7 days":

MD Intervention

Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication/treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects of medications.

Nursing Intervention

"Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

2. Patient A12, T.P. dated 9/10/15, had the following interventions for the short term goal, "Pt [patient] will remain safe during hospital stay thru D/C [discharge]":

MD Intervention

"Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication/treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects of medications."

Nursing Interventions

a. "Maintain on precautions with safety Q 15 min [every 15 minutes] checks."

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

3. Patient A13, T.P. dated 8/25/15, had the following interventions for the short term goal, "[Patient] impulses to harm self will diminish while hospitalized for 7-10 days":

MD Intervention

"Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication/treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects of medications."

Nursing Interventions

a. "Maintain on close obs [observation] /suicide precautions with [checks] every 15 minutes."

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

4. Patient A16, T.P. dated 9/8/15, had the following interventions for the short term goal, "Pt [patient] will remain free from harm and demonstrate decreased SI [suicide ideation] and anxiety within 7 days":

MD Intervention

"Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication/treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects of medications."

Nursing Interventions

a. "Maintain on suicide precautions with close observation levels."

b. "Administer medications as ordered by the physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

The interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

5. Patient A23, T.P. dated 9/2/15, had the following interventions for the short term goal, "Pt [patient] to report [decreased] depression, [no] SI [suicidal ideation], [increased] ADLs [activities of daily living], [decreased] impulsivity x 7":

MD Intervention

"Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication/treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects of medications."

Nursing Interventions

a. "Maintain on SP [suicide precautions] and CO [close observation] with Q15 min [every 15 minutes] checks.

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regard indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

6. Patient A25, T.P. dated 9/1/15, had the following interventions for the short term goal, "[Patient] will exhibit an [increase] in mood stability and report [no] suicidal thoughts within 5-7 days":

MD Intervention

"Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication/treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects of medications."

Nursing Interventions

a. "Maintain on C/O [close observation], S/P [suicide precautions], absc. [abscond] precautions with Q15 min [every 15 minutes] checks."

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

7. Patient B1, T.P. dated 9/9/15, had the following interventions for the short term goal, "Increase desire to live":

MD Intervention

"Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication/treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects of medications."

Nursing Interventions

a. "Maintain suicide precautions with close observation levels".

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

8. Patient B4, T.P. dated 9/1/15, had the following interventions for the short term goal, "Pt [patient] will maintain safety for the next 72 [hours]":

MD Intervention

"Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication/treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects of medications."

Nursing Interventions

a. "Maintain on S/P [suicide precautions], A/P [abscond precautions], C/O [close observation] precautions with low lethality levels."

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.


B. Policy Review

The facility policy PCS-1.10 titled "Multidisciplinary Treatment Plan" (revised 6/14) states, "Individualized interventions to meet the goals prescribe an integrated service of therapies and activities, and specify schedules for the provision of services including frequency. Interventions clearly communicate what the plan is intended to accomplish and the means for achieving the goal. The statement of the intervention includes: Who will carry out the intervention; What action will be taken; How the action occurs and how frequently; How much assistance the patient requires."


C. Interviews

1. On 9/15/15 at 9:10 a.m. MD 1 stated, "You are right, it is the same intervention on
every chart."

2. On 9/15/15 at 9:15 a.m. the Clinical Director stated, "I see we need to work on making interventions more specific to the patient."

3. On 9/14/15 at 10:30 a.m. RN1 stated, "I know the interventions are basically the same
for everyone."

4. On 9/15/15 at 1:00 p.m. the Director of Nursing stated, "I know they are not individualized. We have been told this before. It requires a culture change."

Based on record review, policy review and interview, it was determined that the facility failed to ensure that the staff member responsible for each intervention was specifically identified in the Multidisciplinary Treatment Plans (MTPs ) of eight (8) of eight (8) active sample patients (A9, A12, A13, A16, A23, A25, B1 and B4). This deficiency resulted in the patient and other staff being unaware of which staff person was responsible for the intervention being implemented.

Findings:

A. Record Review

The following patients (date of MTP in parenthesis) had no staff names listed for the MD and Nursing interventions: A9 (9/9/15), A12 (9/10/15), A13 (8/25/15), A16 (9/8/15), A23 (9/2/15), A25 (9/1/15), B1 (9/9/15) and B4 (9/1/15).


B. Policy Review

The facility policy PCS-1.10 titled "Multidisciplinary Treatment Plan" states, "The statement of the intervention includes: Who will carry out the intervention." It did not mention the need to include the name of each responsible person.


C. Interviews

1. On 9/15/15 at 9:15 a.m., the Clinical Director stated, "No, the interventions do not have staff names listed."

2. On 9/15/15 at 1:10 p.m., the Director of Nursing stated, "Individual staff members are not identified for the interventions."

Based on record review and interview, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility.

Specifically, the Medical Director failed to assure that:

1. Psychiatric Evaluations included an inventory of specific patient assets that could be used in treatment planning for five (5) of eight (8) active sample patients (A12, A13, A16, A23 and A25). The failure to identify patient assets can impair the treatment team's ability to develop treatment interventions utilizing the individual strengths of each patient. (Refer to B117)

2. Multidisciplinary Treatment plans identified specific measurable short-term goals based on the individualized patient's needs for eight (8) of eight (8) active sample patients (A9, A12, A13, A16, A23, A25, B1 and B4). This failure hinders the ability of the team to measure changes in the patient and may lead to fragmentation of care. (Refer to B121)

3. Specific physician and nursing psychiatric interventions based on the assessed needs for eight (8) of eight (8) active sample patients (A9, A12, A13, A16, A23, A25, B1 and B4) were included in the multidisciplinary treatment plans. This deficiency results in a failure to guide treatment staff to achieve measurable, behavioral outcomes. (Refer to B122)

4. The staff member responsible for each intervention was specifically identified by name and discipline in eight (8) of eight (8) active sample patients' treatment plan (A9, A12, A13, A16, A23, A25, B1 and B4). This failure results in the patient and other staff being unaware of which staff person was responsible for the intervention being implemented. (Refer to B123)

Based on record review, policy review and interview, the Director of Nursing failed to ensure that the treatment plans for eight (8) of eight (8) sample patients (A9, A12, A13, A16, A23, A25, B1 and B4) contained specific, individualized nursing interventions. This deficiency resulted in a failure to guide nursing staff to achieve behavioral outcomes.

Findings:

A. Record Review

1. Patient A9, MTP dated 9/9/15, had the following nursing intervention for the short term goal, "Patient will remain free from harm and demonstrate decreased depression and SI [suicidal ideation] within 7 days":

"Nursing will assess lethality twice daily."

This intervention was preprinted on the form and was a generic discipline task. The intervention was not individualized.

2. Patient A12, MTP dated 9/10/15), had the following nursing interventions for the short term goal, "Pt [patient] will remain safe during hospital stay thru D/C [discharge]":

a. "Maintain on precautions with safety Q 15 min [every 15 minutes] checks."

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

3. Patient A13, MTP dated 8/25/15, had the following nursing interventions for the short term goal, "[Patient's] impulse to harm self will diminish while hospitalized for 7-10 days":

a. "Maintain on close obs [observation] /suicide precautions with [checks] every 15 minutes."

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

4. Patient A16, MTP dated 9/8/15, had the following nursing interventions for the short term goal, "Pt [patient] will remain free from harm and demonstrate decreased SI [suicide ideation] and anxiety within 7 days":

a. "Maintain on suicide precautions with close observation levels."

b. "Administer medications as ordered by the physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

The interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

5. Patient A23, MTP dated 9/2/15, had the following nursing interventions for the short term goal, "Pt [patient] to report [decreased] depression, [no] SI [suicidal ideation], [increased] ADLs [activities of daily living], [decreased] impulsivity x 7":

a. "Maintain on SP [suicide precautions] and CO [close observation] with Q15 min [every 15 minutes] checks."

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regard indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

6. Patient A25, MTP dated 9/1/15, had the following nursing interventions for the short term goal, "[Patient] will exhibit an [increase] in mood stability and report [no] suicidal thoughts within 5-7 days":

a. "Maintain on C/O [close observation], S/P [suicide precautions], absc. [abscond] precautions with Q15 min [every 15 minutes] checks."

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. " Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

7. Patient B1, MTP dated 9/9/15, had the following nursing interventions for the short term goal, "Increase desire to live":

a. "Maintain suicide precautions with close observation levels".

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.

8. Patient B4, MTP dated 9/1/15, had the following nursing interventions for the short term goal, "Pt [patient] will maintain safety for the next 72 [hours]":

a. "Maintain on S/P [suicide precautions], A/P [abscond precautions], C/O [close observation] precautions with low lethality levels."

b. "Administer medications as ordered by physician and monitor side effects. Provide health teaching regarding indications and side effects."

c. "Nursing will assess lethality twice daily."

These interventions were preprinted on the form and were generic discipline tasks. The interventions were not individualized.


B. Policy Review

The facility policy PCS-1.10 titled "Multidisciplinary Treatment Plan" (revised 6/14) states, "Individualized interventions to meet the goals prescribe an integrated service of therapies and activities, and specify schedules for the provision of services including frequency. Interventions clearly communicate what the plan is intended to accomplish and the means for achieving the goal. The statement of the intervention includes: Who will carry out the intervention; What action will be taken; How the action occurs and how frequently; How much assistance the patient requires."


C. Interviews

1. On 9/15/15 at 9:10 a.m. MD 1 stated, "You are right, it is the same intervention on every chart."

2. On 9/15/15 at 9:15 a.m. the Clinical Director stated, "I see we need to work on making interventions more specific to the patient."

3. On 9/14/15 at 10:30 a.m. RN1 stated, "I know the interventions are basically the same for everyone."

4. On 9/15/15 at 1:00 p.m. the Director of Nursing stated, "I know they are not individualized. We have been told this before. It requires a culture change."

Based on record review and interview, the Social Work Director failed to ensure that Psychosocial Assessments included individualized recommendations for social work services from the data gathered for six (6) of eight (8) active sample patients (A9, A12, A13, A16, A23 and A25). As a result, specific social work recommendations regarding treatment of patient's psychosocial problems were not described for the treatment team.

Findings include:

A. Record Review

1. Patient A5 was admitted on 9/7/15. The Psychosocial Assessment, no date and signing, stated under "Assessed Needs for Treatment": "Pt [patient] to meet 1:1 [one to one] daily x7 [with] psychiatrist, 1:1 3x [times] [with] c.c. [clinical counselor - also known as social worker at this facility] & [and] attend minimum of 1 [one] clinical group daily x7." There was no mention of the specific role of the social worker in treatment and discharge planning for this patient.

2. Patient A12 was admitted on 9/9/15. The Psychosocial Assessment, dated 9/9/15, stated under assessed needs for treatment: "Gather [illegible word], individual therapy, psychiatry, TA Therapeutic Activity] gps [groups], milieu gp. [group], teach pt. healthy coping skills, ¿ [increase] supports."

There was no mention of the specific role of the social worker in treatment and discharge planning for this patient.

3. Patient A13 was admitted on 8/25/15. The Psychosocial Assessment, dated 8/26/15, stated under "Assessed Needs for Treatment": "[Name of patient] will meet c.c. 3x weekly and prn [as needed] for individual counseling, will attend groups and meet with psychiatrist daily, will be re-linked to BPC [name of local state hospital] OP [outpatient] clinic. There was no mention of the focus or purpose of re-linking the patient to the state hospital or which discipline would be doing the referral.

4. Patient A16 was admitted on 9/8/15. The Psychosocial Assessment, dated 9/8/15, stated under "Assessed Needs for Treatment": "Pt to meet 1:1 3x7 with c.c., 1:1 daily [with] psychiatrist, & attend minimum 1[one] clinical group daily." There was no mention of the specific role of the social worker in treatment and discharge planning.

5. Patient A23 was admitted on 9/2/15. The Psychosocial Assessment, dated 9/3/15, stated under "Assessed Needs for Treatment": "Pt to meet 1:1 daily x7 [with] c.c. 1:1 daily x7 [with] psychiatrist, & to attend minimum of 1 clinical group daily x7." There was no mention of the specific role of the social worker in treatment and discharge planning.

6. Patient A25 was admitted on 8/31/15. The psychosocial Assessment, dated 9/1/15, stated under "Assessed Needs for Treatment": "[Name of patient] will meet [with] c.c. 3x weekly and prn for individual counseling, will attend groups and meet [with] psychiatrist daily, will be re-linked to [name of nurse practitioner] at Brylin OP and linked to OP counselor." There was no mention of the specific role of the social worker in treatment and discharge planning.


B. Interview

In an interview on 9/15/15 at 8:33 a.m., the lack of including the specific individualized social work role on the Psychosocial Assessments was discussed with the Director of Social Work. He stated, "The things you are asking about are in the Progress Notes, but I'll talk to the staff about including them (social work roles) on the Psychosocial Assessments too."