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Based on medical record review, policy review, and interview, the facility failed to provide psychosocial assessments that met professional social work standards. These assessments failed to include conclusions and recommendations that described anticipated social work roles in treatment and discharge planning for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure results in a lack of professional social work treatment services and/or lack of input to the treatment team to assist in the care of the patient during hospitalization.

Findings Include:

A. Medical Records

Patient A1's Psychosocial Assessment dated11/15/19, Patient A2's Psychosocial Assessment dated 11/18/19,

Patient A3's Psychosocial Assessment dated 11/18/19, Patient A4's Psychosocial Assessment dated 11/15/19,

Patient A5's Psychosocial Assessment dated 11/18/19, Patient A6's Psychosocial Assessment dated 11/18/19,

Patient A7's Psychosocial Assessment dated 11/18/19, and Patient A8's Psychosocial Assessment dated 11/15/19,
all failed to indicate conclusions based on the data obtained and recommendations for the Social Work role in treatment.

B. Policy Review

Hospital Policy, "Social Services," Reference Number 6008, failed to identify the requirement for Conclusions and Recommendations for Social Work treatment and interventions.

C. Interviews

In an interview on 11/19/19 the Director of Social Work concurred with the deficient findings regarding the Social Work policy and the lack of Conclusions and Recommendations in the Psychosocial Assessments reviewed.

Based on record review, policy review, and interview, the facility failed to ensure that goals listed on the Master Treatment Plans (MTP) addressed individualized patient needs. Specifically, the facility identified identical generic treatment goals for different patients with similarly identified problems for five (5) of the eight (8) sample patients (A2, A3, A5, A6, and A7). In addition, goals were not measurable for seven of eight sample patients. (A1, A2, A4, A5, A6, A7, and A8.) This results in a document that fails to identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to actually measure individual progress in care.

Findings Include:

A. Identical Treatment Goals

1. The 11/18/19 MTPs for both Patients A2 and A3 had the identified problem, "Potential for Self-Harm." For this problem, Patients A2 and A3 had the Long-Term Goal (LTG), "[Patient] will deny suicidal thoughts for 3 days prior to discharge." The Short-Term Goal (STG) for both patients was identical to the LTG, "[Patient] will deny suicidal thoughts for 3 days prior to discharge."

2. The MTPs (all dated 11/18/19) for Patient A5, Patient A6, and Patient A7 had the same identified problem, "Alteration in Mood-Depressed." The STG goal for this problem was identical for all three patients, "[Patient] will demonstrate enjoyment in social or recreational activities by day 4 prior to discharge."

B. Unmeasurable Goals

1. The 11/15/19 MTP for Patient A1 had for the identified problem, "Aggression Towards Others," the unmeasurable STG goal, "[Patient] will verbalize feelings of anger in a controlled, assertive, socially appropriate way for 3 days prior to discharge."

2. The 11/18/19 MTP for Patient A2 had for the identified problem, "Potential for Self-Harm," the STG goal, "[Patient] will seek out staff when self-harm feelings occur during hospital stay." This goal is unmeasurable and puts the responsibility on the patient to assess his/her feelings and seek out staff instead of staff assessing the patient.

3. The 11/15/19 MTP for Patient A4 had for the identified problem, "Ineffective Individual Coping," the unmeasurable LTG goal, "Will demonstrate use of more adaptive coping skills by discharge AEB [As Evidenced By] appropriateness of interaction and willingness to participate in therapeutic community."

4. The MTPs (all dated 11/18/19) for Patient A5, Patient A6, and Patient A7 had the same identified problem, "Alteration in Mood-Depressed." The unmeasurable STG goal for this problem was identical for all three patients, "[Patient] will demonstrate enjoyment in social or recreational activities by day 4 prior to discharge."

5. The 11/15/19 MTP for Patient A8 had for the identified problem, "Ineffective Coping Skills," the unmeasurable STG, "Will refrain from use of harmful/negative coping skills for 3 days prior to discharge."

C. Policy

Hospital Policy, "Plan of Care," Revised 01/31/19, stated that the plan of care was to include, "Measurable goals and objectives based on the assessed needs, strengths and the patient's limitations," and "Expressed in behavioral terms that specify measurable indices of progress."

D. In an interview on 11/19/19 at 11:30 p.m., the Corporate Vice-President of Nursing stated that she agreed that the goals in the MTP were not measurable and were not individualized.

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans (MTP) for six (6) of eight (8) sample patients (A1, A2, A3, A5, A6, and A7) included physician and nursing treatment modalities (interventions) that were individualized based on patient needs. Instead, modalities were identical and generic regardless of the identified problems. This failure results in a treatment plan that does not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings Include:

A. Physician/Nursing Treatment Modalities

1. The 11/15/19 MTP for patient A1 listed the two problems, "Potential for Self-Harm," and "Aggression Towards Others." Both problems had the same physician intervention, "Physician Assessment to assess mood, mental status, and effectiveness of medications," and the same nursing intervention, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

2. The 11/18/19 MTP for Patient A2 listed two problems, "Potential for Self-Harm," and "Alteration in Mood-Depressed." Both problems had the same physician interventions, "Physician Assessment to assess mood, mental status, and effectiveness of medications," and the same nursing intervention, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

3. The 11/18/19 MTP for Patient A3 listed two problems, "Potential for Self-Harm," and "Alteration in Mood-Depressed." Both problems had the same physician interventions, "Physician Assessment to assess mood, mental status, and effectiveness of medications," and the same nursing intervention, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

4. The 11/18/19 MTP for Patient A5 listed the problem, "Alteration in Mood-Depression." The physician intervention was stated, "Physician Assessment to assess mood, mental status, and effectiveness of medications," and the nursing intervention was stated, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

5. The 11/15/19 MTP for Patient A6 listed the problem, "Alteration in Mood-Depression." The physician intervention was stated, "Physician Assessment to assess mood, mental status, and effectiveness of medications," and the nursing intervention was stated, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

6. The 11/18/18 MTP for Patient A7 listed the problem, "Alteration in Mood-Depression." The physician intervention was stated, "Physician Assessment to assess mood, mental status, and effectiveness of medications," and the nursing intervention was stated, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

B. Interview

In an interview on 11/19/19 at 11:30 a.m., the Corporate Vice-President of Nursing stated that she agreed that the interventions for physicians and nurses were identical for many of identified problems.

Based on medical record review and interview, the hospital failed to ensure that the staff members responsible for each intervention were specifically identified in four (4) of eight (8) treatment plans. (A2, A3, A4, and A8). This failure has the potential to result in the patient and other staff being unaware of who is responsible for the interventions being implemented and documented.

Findings Include:

A. Medical Records

1. Patient A2's Master Treatment Plan (MTP) dated 11/18/19 listed for the Problem, "Potential for Self Harm," the intervention, "Physician assessment to assess mood, mental status, and effectiveness of medication." The specific person listed as responsible for this intervention was "Dr." For the intervention, "RN assessment to determine mood, effectiveness of patient education on self-control measures and patient perception of effectiveness of medications," the specific person listed as responsible was "RN."

2. Patient A3's MTP, dated 11/18/19, listed for the Problem, "Potential for Self Harm," the intervention, "Physician assessment to assess mood, mental status, and effectiveness of medications." The specific person listed as responsible for this intervention was "Dr."

3. Patient A4's MTP, dated 11/15/19, listed for the Problem, "Ineffective Individual Coping," the intervention, "Encourage group attendance and participation." The staff listed as responsible were identified as "All" with the disciplines listed as, "RN, Team, SW [Social Work], RT [Recreational Therapy]."

4. Patient A8's MTP dated, 11/15/19, listed for the Problem, "Ineffective Individual Coping," the intervention, "Encourage group attendance and participation." The staff listed as responsible were identified as "All" with the disciplines listed as, "RN, Team, SW, RT."

B. Interview

In an interview on 11/19/19 at 11:30 a.m., the Corporate Vice President of Nursing concurred with the findings regarding the absence of specific responsible staff members responsible for the treatment interventions.

Based on record review, policy review, and interview, the medial director failed to ensure the following:

1. That goals listed on the Master Treatment Plans (MTP) addressed individualized patient needs. Specifically, the facility identified identical generic treatment goals for different patients with similarly identified problems for five (5) of the eight (8) sample patients (A2, A3, A5, A6, and A7). In addition, goals were not measurable for seven (7) of eight (8) sample patients. (A1, A2, A4, A5, A6, A7, and A8.) This results in a document that fails to identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to actually measure individual progress in care. (Refer to B121)

2. That Master Treatment Plans (MTP) for six of eight sample patients (A1, A2, A3, A5, A6, and A7) included physician and nursing treatment modalities (interventions) that were individualized based on patient needs. Instead, modalities were identical and generic regardless of the identified problems. This failure results in a treatment plan that does not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

3. Based on medical record review and interview, the hospital failed to ensure that the staff members responsible for each intervention were specifically identified in four of eight treatment plans. (A2, A3, A4, and A8). This failure has the potential to result in the patient and other staff being unaware of who is responsible for the interventions being implemented and documented. (Refer to B123)

Interviews

In an interview on 11/20/19 at 8:45 a.m., the CEO and the Medical Director were informed of the deficient findings regarding MTP goals, interventions, and staff responsibilities. They voiced understanding of the findings and did not have questions regarding the findings.

Based on record review and interview, the Director of Nursing failed to ensure that:

l. The Master Treatment Plans (MTP) for six (6) of eight (8) sample patients (A1, A2, A3, A5, A6, and A7) included nursing treatment modalities (interventions) that were individualized based on patient needs. Instead, modalities were identical and generic regardless of the identified problems. This failure results in a treatment plan that does not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings Include:

A. Nursing Treatment Modalities

1. The 11/15/19 MTP for patient A1 listed the two problems, "Potential for Self-Harm," and "Aggression Towards Others." The nursing intervention for both identified problems was, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

2. The 11/18/19 MTP for Patient A2 listed two problems, "Potential for Self-Harm," and "Alteration in Mood-Depressed." The nursing intervention for both problems was, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

3. The 11/18/19 MTP for Patient A3 listed two problems, "Potential for Self-Harm," and "Alteration in Mood-Depressed." Both problems had the same nursing intervention, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

4. The 11/18/19 MTP for Patient A5 listed the problem, "Alteration in Mood-Depression." The nursing intervention was stated, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

5. The 11/15/19 MTP for Patient A6 listed the problem, "Alteration in Mood-Depression." The nursing intervention was stated, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

6. The 11/18/18 MTP for Patient A7 listed the problem, "Alteration in Mood-Depression." The nursing intervention was stated, "RN Assessment to determine mood, effectiveness of patient education on self-control measure and patient perception of effectiveness of medications."

B. Interview

In an interview on 11/19/19 at 11:30 p.m., the Corporate Vice-President of Nursing stated that she agreed that the nursing interventions were identical for many of identified problems.

ll. The nursing staff members responsible for each intervention were specifically identified in three of eight treatment plans. (A2, A4, and A8). This failure has the potential to result in the patient and other staff being unaware of which nurse is responsible for the interventions being implemented and documented.

Findings Include:

1. Patient A2's Master Treatment Plan (MTP) dated 11/18/19 listed for the Problem, "Potential for Self Harm," the intervention, "RN assessment to determine mood, effectiveness of patient education on self-control measures and patient perception of effectiveness of medications." The specific nursing staff listed as responsible was identified as, "RN."

2. Patient A4's MTP, dated 11/15/19, listed for the Problem, "Ineffective Individual Coping," the intervention, "Encourage group attendance and participation." The specific nursing staff listed as responsible was identified as, "RN."

3. Patient A8's MTP dated, 11/15/19, listed for the Problem, "Ineffective Individual Coping," the intervention, "Encourage group attendance and participation." The specific nursing staff listed as responsible was identified as, "RN."

B. Interviews

1. In an interview on 11/19/19 at 11:30 p.m., the Corporate Vice-President of Nursing stated that she agreed with the finding that the interventions listed in the MTPs did not always identify the specific nurse responsible for the interventions and instead listed the generic staff "RN."

2. In an interview on 11/20/19 at 8:45 a.m., the CEO and the Medical Director were informed of the deficient findings regarding MTP interventions and the lack of specific nursing staff responsibilities. They voiced understanding of the findings and did not have questions regarding the findings.