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Based on record review and interview, the facility failed to provide comprehensive Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A4, A5, A13, B3, B6, B10 and B16). The MTPs were convoluted documents that were developed from a new computer program that failed to: 1) clearly define disabilities (problems) to be addressed (Refer to B119); 2) list observable and/or measurable goals with specified target dates (Refer to B121); 3) individualize treatment interventions (Refer to B122); and/or 4) identify staff responsible for implementation and evaluation of the interventions. (Refer to B123) Failure to develop Master Treatment Plans with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

During interview on 3/20/12 at 3:20p.m., the Clinical Director and the DON reported that they were aware of current problems with treatment plans. The DON stated that the clinical staff seems to have "forgotten what they were supposed to speak to in a treatment plan. They are "grabbing on to options in the computer program without giving specifics."

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTP) clearly defined the disabilities (problems) to be addressed for 3 of 8 active sample patients (A1, B3 and B6). The problem statements were generalized comments or a group of symptoms, rather than specific problem behaviors to be reduced or resolved. This failure results in a fragmented, confusing master treatment plan that can adversely affect-making and can prevent the patient from receiving necessary treatment in a timely manner.

Findings include:

A. Record Review

1. Patient A1-MTP update 3/18/12:

a. A problem was identified as a list of symptoms: "reported racing thoughts, restless sleep, increase anxiety, increase [sic] irritability symptoms associated with an effective disorder." The specific behavioral problem to be resolved/reduced was not clear.

b. A problem was identified as a group of symptoms: "reports mood swings, restless [sic] behaviors and sleep." The specific behavioral problem to be resolved/reduced was not clear.

c. A problem was identified as "paranoia associated with a psychotic disorder." The related behavioral problem was not identified.

2. Patient B3-MTP update 3/17/12:

A problem was identified as "Has a history of recurrent mood swings and acting out episodes, during which he engages in aggression toward himself and others, which act as potential barriers to achieving and/or maintaining his self identified life goals." This problem statement failed to clearly identify the issue to be addressed.

3. Patient B6-MTP update 3/17/12:

A problem was identified as "recurrent anger management difficulties and behavioral issues." This problem statement failed to clearly identify the specific behavioral issues to be addressed.

B. Interview

During an interview on 3/20/12 at 3:20p.m., the Clinical Director stated that some of the problems were not clearly stated on the treatment plans.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) for 6 of 8 active sample patients (A1, A5, B3, B6, B10 and B16) that included treatment goals with specific measurable patient behaviors to be achieved. This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine effectiveness of interventions based on changes in patient behaviors.

Findings include:

A. Patient A1-MTP update 3/18/12:

For the problem "reported racing thoughts, restless sleep, increase anxiety, increase [sic] irritability symptoms associated with an effective disorder," a non-measurable goal was stated as "will demonstrate an understanding of at least 1 behavioral strategy [sic] and the cost and benefits of the available medications to help in re-establishing an appropriate sleep pattern."

For the problem, "reports mood swings, restless [sic] behaviors and sleep," a non-measurable goal was stated as "Will report/exhibit normal activity level."

For the problem "paranoia associated with a psychotic disorder," the related behavioral goal was not identified.

B. Patient A5-MTP update 3/16/12:

For the problem, "depressed mood as evidenced by poor sleep, feeling sad, racing thoughts, problems with roommates at serv [service] home," a non-measurable goal was stated as "Will be decreased depressed [sic], mood will stabilize, sleep will improve."

C. Patient B3-MTP update 3/17/12:

For the problem "Has a history of recurrent mood swings and acting out episodes, during which he engages in aggression toward himself and others, which act as potential barriers to achieving and/or maintaining his self identified life goals," non-measurable goals were stated as "Will show an increased ability to maintain personal safety and safe behavior toward others" and "Will demonstrate an improvement in managing out of control behaviors, comply with directions of authority figures..."

D. Patient B6-MTP update 3/17/12:

For the problem, "recurrent anger management difficulties and behavioral issues," non-measurable goals were stated as "The client will show an increased ability to maintain personal safety and safe behavior towards others" and "The client's anger and behavior outbursts will decrease, and overall level of functioning will sufficiently improve as evidenced by...will demonstrate an improvement in managing her out of control behaviors, comply with the directions of authority figures..."

During an interview which included a review of Patient B6's treatment plan on 3/20/12 at 3:20p.m., the Clinical Director stated that the above goals were not measurable.

E. Patient B10-MTP update 3/16/12:

For the problem, "History of recurrent depressive episodes, to include SI (Suicide Ideation) and self-injurious behavior," a non-measurable goal was stated as "Will show an increased ability to maintain personal safety."

F. Patient B16-MTP dated 3/19/12:

For the problem, "Recent threat to harm self," a non-measurable goal was stated as "...engage in building skills to cope with emotions."

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified individualized interventions to address the specific treatment needs of 8 of 8 active sample patients (A1, A4, A5, A13, B3, B6, B10 and B16). The listed interventions on the treatment plan were stated as generic role functions, patient actions, or were absent. These failures can result in lack of staff coordination in providing individualized treatment, potentially delaying patient improvement and discharge from hospital.

Findings include:

A. Patient A1-MTP update 3/18/12:

For the problem, "reports mood swings, restless behaviors and sleep," a social work intervention was stated as patient actions: "Will regularly meet with assigned clinician for assessment purposes as well as for discharge planning measures. Will participate ein theraptuci [sic] groups on unit to gian [sic] better understanding of management of illness outside of an inpatient setting. Will accept recommendations for housing and aftercare."

During an interview on 3/20/12 at 10:15a.m., SW C4 stated that the above intervention was stated as patient actions, rather than staff actions.

There were no physician interventions listed for care of this patient other than medications.

There were no nursing interventions documented to direct nursing personnel to care for this patient in the clinical areas.

B. Patient A4-MTP update 3/16/12:

For the problem, "depressed mood as evidenced by exacerbation of depression and positive suicide," there were no identified physician interventions. A generic nursing intervention was stated as "...will assess and monitor mental status and physical status, monitor vital signs, provide regular diet and will monitor sleep pattern and will monitor adls (activities of daily living skills)."

For the problem, "Reports history of increased anxiety and suicide attempt (s)," a social work intervention was stated as patient actions: "will meet with assigned clinician for assessment, discharge planning and coordination of care realted [sic] activities. Will provide consent to involve DYFUS [Department of Youth Services] in treatment and discharge planning. Will meet with clinical for supportive measures and to develop at least 5 coping strategies to deal with life related stressors."

C. Patient A5-MTP update 3/16/12:

For the problem, "depressed mood as evidenced by poor sleep, feeling sad, racing thoughts, problems with room mates at serv [service] home," a nursing intervention was stated in generic terms as "med [medication] and illness education, encourage group participation, discuss 3 positive coping skills, encourage client to participate in (his/her) treatment plan and (his/her) treatment."

D. Patient A13-MTP dated 3/15/12:

For the problem, "Reports history of suicide attempt(s)," a treatment team intervention was stated as a patient goal: "Will develop positive coping skills to assist with depression and bereavement."

E. Patient B3-MTP update 3/17/12:

For the problem "Has a history of recurrent mood swings and acting out episodes, during which he engages in aggression toward himself and others, which act as potential barriers to achieving and/or maintaining his self identified life goals," a generic physician intervention (also included patient actions) was listed as "Client will continue to take [his/her] medication as prescribed. Medication adjustments will be made as necessary and client will be monitored for any adverse reactions."

A generic nursing intervention was listed as "Staff will provide a safe and secure therapeutic milieu, provide observation to ensure safety, monitor vital signs, medicate as ordered, observe for target symptoms and adverse side effects to medication, and encourage group participation.

Social Work interventions were stated as patient goals/actions as "Will participate in individual therapy to address personal and family history, self-esteem decision making, coping skills and resources"; "Will participate in group therapy to address [his/her] thoughts and emotions related to his family issues at home and behavioral issues at school, as well as improved communication, coping, and social skills in a supportive setting" and "Will participate in family therapy to address communication issues and family dynamics that contribute to symptom maintenance."

F. Patient B6-MTP dated 3/17/12:

For the problem identified as "recurrent anger management difficulties and behavioral issues," a generic physician intervention (also included some parts stated as patient actions) was listed as "Client will continue to take her medication as prescribed in order to help improve (his/her) overall mood and behavior. Client will be monitored for target symptoms and adverse reactions, and medication will be adjusted as needed."

During an interview which included a review of Patient B6's treatment plan on 3/20/12 at 3:20p.m., the Clinical Director stated that the above physician intervention "should have been more specific."

A nursing intervention was presented in generic terms as "Staff will provide a safe and secure therapeutic milieu, provide observation to ensure safety, monitor vital signs, medicate as ordered, observe for target symptoms and adverse side effects to medication and encourage group participation."

During an interview on 3/20/12 at 10:45a.m., the DON stated that the above nursing intervention was an "intervention chosen (from the computer data base) that should have been individualized."

G. Patient B10-MTP update 3/16/12:

For the problem, "History of recurrent depressive episodes, to include SI (Suicide Ideation) and self-injurious behavior," a generic physician intervention (also included some parts stated as patient actions) was listed as "Client will take (his/her new medication as prescribed in order to help improve (his/her) overall mood and impulsive behavior. Client will be monitored for target symptoms and adverse reactions, and medication will be adjusted as needed."

A nursing intervention was presented in generic terms as "Staff will provide a safe and secure therapeutic milieu, provide observation to ensure safety, monitor vital signs, medicate as ordered, observe for target symptoms and adverse side effects to medication and encourage group participation."

During an interview on 3/20/12 at 10:45a.m., the DON stated that the above nursing intervention was an "intervention chosen (from the computer data base) that should have been individualized."

Social Work interventions were stated as patient goals/actions: "Will participate in individual therapy to address personal and family history, self-esteem, decision making, coping skills and resources," "Will participate in group therapy to address [his/her] depression, urges to cut, family issues, and any other stressors in a supportive setting," and "Will participate in family therapy to address communication issues and family dynamics that contribute to symptom maintenance."

H. Patient B16-MTP dated 3/19/12:

For the problem, "Recent threat to harm self," a nursing intervention was presented in generic terms as "Provide a safe, secure and therapeutic milieu, monitor vital signs, medicate as ordered observing for target symptoms and adverse side effects, assess for signs/symptoms of imminent harm to self/others, and provide observation to ensure safety."
During an interview which included a review of the above intervention on 3/20/12 at 10:45a.m., the DON stated that this was an "intervention chosen (from the computer data base) that should have been individualized."

Based on record review and interview, the facility failed to ensure that the name and discipline of the staff persons responsible for specific aspects of care were listed on the Master Treatment Plans (MTPs) of 5 of 8 active sample patients (A5, A13, B3, B6 and B10). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

1. Patient A5-MTP update 3/16/12:

For the problem, "depressed mood as evidenced by poor sleep, feeling sad, racing thoughts, problems with room mates at serv [service] home," a nursing intervention stated as "med [medication] and illness education, encourage group participation, discuss 3 positive coping skills, encourage client to participate in (his/her) treatment plan and (his/her) treatment." The staff member responsible for the nursing intervention was not identified in the MTP.

2. Patient A13-MTP dated 3/15/12:

For the problem, "Reports history of suicide attempt(s)," interventions were assigned to "Treatment Team" rather than to a specific team member.

3. Patient B3-MTP update 3/17/12:

For the problem "Has a history of recurrent mood swings and acting out episodes, during which he engages in aggression toward himself and others, which act as potential barriers to achieving and/or maintaining his self identified life goals," a nursing intervention was "Staff will provide a safe and secure therapeutic milieu, provide observation to ensure safety, monitor vital signs, medicate as ordered, observe for target symptoms and adverse side effects to medication, and encourage group participation." The staff member responsible for the nursing intervention was not identified on the MTP.

4. Patient B6-MTP update 3/17/12:

For the problem identified as, "recurrent anger management difficulties and behavioral issues," the staff member responsible for the listed nursing intervention was not identified on the MTP.

5. Patient B10-MTP update 3/16/12:

For the problem, "History of recurrent depressive episodes, to include SI (Suicide Ideation) and self-injurious behavior," a nursing intervention was presented as "Staff will provide a safe and secure therapeutic milieu, provide observation to ensure safety, monitor vital signs, medicate as ordered, observe for target symptoms and adverse side effects to medication and encourage group participation." The staff member responsible for the nursing intervention was not identified on the MTP.

B. Interview

During an interview which included a review of treatment plans on 3/20/12 at 3:20p.m., the Clinical Director and the DON acknowledged that some of the interventions were not assigned to specific clinical team members on some of the treatment plans.

Based on document review and interview, the facility failed to:

I. Ensure that discharge summaries were dictated, transcribed and filed within 30 days of discharge for 2 of 5 patients whose discharge records were reviewed (D3 and D5). This deficiency results in failure to communicate in a timely manner the final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with outpatient providers.

Findings include:

A. Document Review

1. Patient D3

According to the discharge summary, patient D3 was discharged on January 26, 2012 and discharge summary was dated March 19, 2012.

2. Patient D5

According to the discharge summary, patient D5 was discharged on February 2, 2012 and discharge summary was dated March 20, 2012.

B. Interview

During an interview on 3/20/12 at 11:45a.m., the DON stated that discharge summaries are to be transcribed within 30 days of discharge.

II. Provide a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than medication for 3 of 5 discharged patients whose records were reviewed (D1, D2 and D4). This compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

A. Document Review

1. Patient D1

Specific treatment strategies, and patient's response to them, were limited in the discharge summary to medication. Brief mention was made of group participation without specific treatment strategies identified: "PT [sic] tolerated both medications well; denied any side effects with medications and reported full remission of psychotic sxs [sic] with no behavioral problems and good group participation during stay."

2. Patient D2

No specific treatment strategies were discussed in the discharge summary.

3. Patient D4

Treatment strategies were identified in the discharge summary without mention of the patient's response to them.

B. Interview

During an interview on 3/20/12 at 3:20, the Clinical Director acknowledged the paucity of information contained in the discharge summaries related to specific treatment strategies and patient responses to them.

Based on document review and interview, the facility failed to ensure that the discharge summaries for 3 of 5 discharged patients (D1, D4 and D5), contained a summary of the patient's condition on the day of discharge, including psychiatric, physical and functional condition. This deficiency results in lack of information about the patient, family and community resources that can be used to prevent future readmissions to the hospital.

Findings include:

A. Document review

1. Patient D1

No mention was made in the discharge summary of the patient's physical or functional status on the day of discharge.

2. Patient D4

No mention was made in the discharge summary of the patient's psychiatric, physical, or functional condition on the day of discharge.

3. Patient D5

No mention was made in the discharge summary of the patient's physical condition on the day of discharge.

B. Interview

During an interview on 3/20/12 at 3:20, the Clinical Director acknowledged the paucity of information contained in the discharge summaries related to psychiatric, physical and functional condition of the patient on the day of discharge.