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Based on record review and interviews, the facility failed to provide medical records that documented comprehensive assessments and planned individualized treatment to be given to patients. Specifically, the facility failed to:

I. Ensure that psychiatric assessments included an inventory of the patient's assets in a descriptive, not interpretive fashion in seven (7) of eight (8) sample patients (A5, A15, B4, C2, C12, and C19). Failure to describe those personal factors, strengths, and/or attributes of each patient compromises the treatment team's ability to develop goals to meet identified needs of each patient. (Refer to B117)

II. Ensure that Master Treatment Plans (MTPs) had clearly defined personal strengths/assets and problem statements written in behavioral and descriptive terms for five (5) of eight (8) active sample patients (A15, B4, C2, C12, and C19). These failures can adversely affect clinical decision-making in formulating goal and intervention statements and can prevent the patient from receiving necessary treatment in a timely manner. (Refer to B119)

III. Develop Master Treatment plans (MTPs) that consistently included short-term goals that were stated in measureable and behavioral terms for seven (7) of eight (8) active sample patients (A2, A15, B4, B10, B13, C2 and C12). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and determine effectiveness of interventions based on changes in patient behaviors. (Refer to B121)

IV. Provide Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A2, A15, B4, B10, B13, C2, C12 and C19) that consistently included individualized active treatment interventions with a delivery method (individual or group sessions), specific focus of treatment, and frequency of contact. Failure to document which specific treatment intervention relates to which patient goal interferes with the assurance of consistency of approach to each patient's problems and may result in prolonged hospitalization for patients. (Refer to B122)





28204

Based on Observations, Record Review and Staff Interview the facility failed to:

1) Provide Psychosocial Assessments that included individualized social work conclusions and recommendations and social work roles in treatment and discharge planning for eight (8) of eight (8) active sample patients. (Refer to B108)

2) Document Physical Examinations for three (3) of eight (8) active sample patients. (Refer to B109)

3) Include an inventory of patients strength, assets and disabilities in the Master Treatment Plans (MTPs). (Refer to B119)

4) Ensure that the Master Treatment Plans included patient related Short Term(ST) and Long Term(LT) goals in observable, measurable, behavioral terms. (Refer to B121)

5) To identify patient specific, individualized treatment modality and focus of intervention. (Refer to B122)

6) Ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the Master Treatment Plan. (Refer to B123)

7) Ensure the Physicians roles and responsibilities were identified in the MTP. (Refer to B125)

8) Ensure that the physicians followed hospital policy and document progress notes in a timely manner for four (4) of eight (8) active sample patients. (Refer to B126)

9) Ensure the discharge summaries are completed in a timely fashion as defined by hospital policy for four (4) of five (5) discharged sample patients. (Refer to B133)

Based on record review and interview, the facility failed to ensure that psychiatric assessments included an inventory of the patient's assets in a descriptive, not interpretive fashion in seven (7) of eight (8) sample patients (A5, A15, B4, C2, C12 and C19). Failure to describe those personal factors, strengths, and/or attributes of each patient compromises the treatment team's ability to develop goals to meet identified needs of patients and limits the team's ability to engage the patient in treatment based on patient strengths.

Findings include:

A. Record review

The Psychiatric Evaluation for the following patients were reviewed (dates of plans in parentheses): A5 (11/25/15); A15 (12/10/15); B4 (11/19/15); B10 (11/25/15); B13 (12/3/15); C2 (11/19/15); C12 (12/5/15); and C19 (12/9/15). This review revealed:

1. Patient A5: in the "Assets" section under "Patient Legal History," the documentation contained no statement related to the patient's assets.

2. Patient A15: in the "Assets" section under "Patient Legal History," the documentation stated, "No Much." There was no statement related to the patient's assets.

3. Patient B4: in the "Assets" section under "Patient Legal History," the documentation stated, "I like my compassionate heart." "Genuine concern for other people."

4. Patient B10: in the "Assets" section under "Patient Legal History," the documentation included the following statement, "Big heart."

5. Patient C2: in the "Assets" section under "Patient Legal History," the documentation contained no statement related to the patient's assets.

6. Patient C12: in the "Assets" section under "Patient Legal History," the documentation included the following statement, "On SSD."

7. Patient C19: in the "Assets" section under "Patient Legal History," the documentation stated, "Nothing." "I could be a good person." There was no statement related to the patient's assets.

B. Staff Interview

In an interview on 12/15/15 at 1:15 p.m., the psychiatric evaluations were reviewed for patient assets to use in treatment. The Medical Director acknowledged that the psychiatric evaluations for the active sample patients did not include an inventory of specific patient assets that could be used in treatment planning and treatment.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) clearly defined patients' personal strengths/assets and problem statements written in behavioral and descriptive terms for five (5) of eight (8) active sample patients (A15, B4, C2, C12, and C19). Specifically, the MTPs included a short list of vague patient traits or external support resources labeled as "strengths," which results in poorly defined goals and interventions. In addition, many of the stated problems on the treatment plans included diagnoses and/or generalized lists of statements or symptoms instead of specific individualized and descriptive clinical symptoms/behaviors. These failures can adversely affect clinical decision-making in formulating goal and intervention statements and can prevent the patient from receiving necessary treatment in a timely manner.

Findings include:

A. Facility policy number SS-058, NUR- 3.36, titled "Multidisciplinary Treatment Plan," last revised 4/22/15, stated "The comprehensive plan and subsequent revisions include, but not limited to the following: the patient's clinical needs, condition, functional strengths, limitations." The use of the word "functional strengths" does not help staff with defining the specific definition of what types of strengths should be cited that are personal attributes, i.e. knowledge, skill, talents. The following patients had assets that were not personal attributes:

1. Active sample patient A15's MTP dated 12/12/15 had as problems: "Bipolar Disorder-depressed. Isolates, loss of interest in current activities." The patient's asset/strength was: "Patient does not recognize strengths, but is persistent." The problem was a diagnosis followed by very general behavior descriptions. The asset was vague and more a staff's opinion than a specific patient strength.

2. Active sample patient B4's MTP dated 11/21/15, had as a problem: "Depressed mood [depression]." The patient's assets/strengths were: "Compassionate heart." The problem was a diagnosis and the strength was a general statement, not a personal attribute of the patient

3. Active sample patient C2's MTP dated 12/8/15, had as problems: "Depressed mood, PTSD [Post-Traumatic Stress Disorder], lack of motivation, hopelessness." The patient's asset/strength was: "Verbally advocated for self-persistent." The problems listed included diagnoses and the strength was not a personal attribute of the patient.

4. Active sample patient C12's MTP 12/4/15, had as problems: "Severe depression and thoughts of harming self-11/11/15 and made attempt 11/9/15." The assets/ strengths were: "housing, on SSD [Social Security Disability]." The problems were not written in descriptive terms and the strengths were not personal attributes of the patient.

5. Active sample patient C19's MTP dated 12/11/15, had as a problem: "Major Depressive Disorder." The assets/strengths were: "honest, verbal, persistent." The problem was a diagnosis, not a specific description of the patient's behavior and the strengths were staff opinions, not personal attributes of the patient.

B. Interview

In an interview on 12/15/15 at 11:15 a.m., the lack of personal strengths on the Master Treatment plans was discussed with the Medical Director. He did not dispute the findings.




30491

Based on record review and interview, the facility failed to develop Master Treatment plans (MTPs) that consistently included short-term goals that were stated in measureable and behavioral terms for seven (7) of eight (8) active sample patients (A2, A15, B4, B10, B13, C2 and C12). The MTPs for these seven active sample patients incorrectly listed staff interventions (rather than patient outcome behaviors) as patients' goals. This deficient practice hampers the ability of the treatment team to provide goal directed treatment and determine effectiveness of interventions based on changes in patient behaviors.

Findings include:

A. Record Review

1. Hospital policy # SS-058, NUR-3.36, titled "Multidisciplinary Treatment Plan," last revised 4/22/15, stated "Treatment goals will be formulated in individualized terms of the patient acquiring new behavior and focused on future patient changes. The goals will be broad or general statements, which provide the mechanism for categorizing and organizing treatment objectives. Treatment objectives will be written in individualized terms of behavior and will be measured in that the behavioral outcome is evident and directly ties to physical events and/or patient report."

2. Active sample patient A2's MTP dated 11/27/15, had as problems: "Bipolar - mixed, racing thoughts, depression, not feeling safe. Isolation." The short-term goals were: "Attend and participate in five (5) of five (5) assignments [sic]. Evaluation and process groups to develop coping skills to manage mood swings. Attend and participate in 14 of 14 recreation groups to increase motivation and decrease isolation. Participate in individual therapy weekly to develop skills to deal with bipolar [sic]. Take medication as prescribe." These are staff goals (What the staff want the patients to accomplish), not patient goals (What the patient wants and needs to accomplish).

3. Active sample patient A15's MTP dated 12/12/15, had as problems: "Bipolar I - depressed, isolates, lost interest in current activities." The non-measurable short-term goal was: "Patient will be able to identify feelings of worthlessness, hopelessness and go to staff for support by 12/1/15." The staff goal listed was: "Take medications as prescribed."

4. Active sample patient B4's MTP dated 11/21/15, had as a problem: "Depressed mood [depression]. The staff short-term goals were: "Take medications as prescribed on a daily basis. Participation in seven (7) recreation groups per week to develop healthy skills to reduce depressed mood and increase socialization. Attend five (5) process and five (5) education groups per week to develop skills to manage depression."

5. Active sample patient B10's MTP dated 11/28/15, had as a problem: "Major depression disorder." The staff short-term goals were: "Attend 4 rec [recreation] groups weekly to increase motivation and decrease isolation. Attend five (5) of five (5) process groups, six (6) of the seven (7) education groups, and six (6) of seven (7) life skills groups to identify/learn coping skills to reduce depression weekly."

6. Active sample patient B13's MTP dated 12/5/15, had as a problem: "Major Depressive Disorder." The non-measureable short-term goal was: "Patient will verbalize a better understanding of depression and his depressed symptoms within 2 weeks of treatment." The staff goal was: "Patient will set up a discharge plan and aftercare services in order to maintain mental health functioning and prevent an increase in depressive symptoms."

7. Active sample patient C2's MTP dated 12/815, had as a problem: "Depression." The staff short-term goals were: "Take medications as prescribed on a daily basis to help reduce depressed mood. Attend five (5) process groups and three (3) education groups to gain skills to cope with depressed mood. Participate in two (2) recreation groups to increase motivation. Increase rec [recreation] group goal [sic] to 10 per week. "

8. Active sample patient C12's MTP dated 12/4/15, had as a problem: "Risk for injury (self-inflicted)." The staff goal was: "Pt. [patient] will attend process group 5x per week." The non-measurable goal was: "Pt. will be able to verbalize thought stopping techniques when thoughts of self-harm occur."

B. Interview

In an interview on 12/15/15 at 8:30 a.m., the non-measurable and staff, not patient, goals were discussed with the Director of Nursing. She did not dispute the findings.





30491

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A2, A15, B4, B10, B13, C2, C12 and C19) that consistently included individualized active treatment interventions with a delivery method (individual or group sessions), specific focus of treatment, and frequency of contact. In addition, the identified goals were listed first, followed by a list of interventions, making it difficult to tell which goals corresponded with which intervention. Failure to document which specific treatment intervention relates to which patient goal interferes with the assurance of consistency of approach to each patient's problems and may result in prolonged hospitalization for patients.

Findings include:

A. Record Review

1. Hospital policy # SS-058, NUR-3.36, titled "Multidisciplinary Treatment Plan", last revised 4/22/15, stated "The role of the treatment intervention is to cause its objective(s) to occur, and if the intervention is appropriate and valid, it can be expected within some set period of time"--- "intervention listed on the 'Individual Comprehensive Treatment Plan' will reflect individualized intervention/care planning rather include [sic] a list of staff modalities with frequency of the modality, without identification of specific intervention, and specify the focus of individual and group treatment modalities."

2. Active sample patient A2's MTP dated 11/27/15, has as short-term goals for problems of "Bipolar- Mixed. Racing thoughts, depression, not feeling safe. Isolation": "Attend and participate in assignments. Evaluation and process groups to develop coping skills to manage swings. Attend and participate in 14 of 14 recreation groups to increase motivation and decrease isolation. Participate in individual therapy weekly to develop skills to deal with Bipolar. Take medications as prescribed."

The interventions listed below the short-term goals were: "Weekly therapy. Five (5) assignment groups and five (5) process groups per week to develop coping skills for [his/her] bipolar symptoms. 14 offered recreation groups to improve motivation and decrease isolation. 2x [times] daily nursing assessments to assess depression & [and] anxiety. 15 minute wellness checks for safety. Medication management and administration daily."

The intervention statements regarding nursing assessment, 15-minute checks, and medication administration were generic discipline tasks that were not individualized and specifically related to what the staff would do to assist the patient to improve presenting symptoms. The intervention statements regarding weekly therapy and medication management did not include a modality (how the intervention would be delivered- individual or group sessions) and focus of treatment. Since the goals and interventions were not numbered, it was difficult to determine which goal went with which intervention.

3. Active sample patient A15's MTP dated 12/12/15, had as short-term goals for problems of "Bipolar I-Depressed. Isolates, lost interest in current activities": "Patient will be able to identify feelings of worthlessness, hopelessness and go to staff for support by 12/25/15. Patient will identify four (4) positive coping strengths, such as developing leisure activities. Patient will engage in 5 minute conversation 2x daily with staff during which [s/he] makes at least two (2) positive self-statements for 2 weeks. Take medications as prescribed."

The interventions listed below the short-term goals were: "Weekly therapy and five (5) process groups per week to develop coping skills for [his/her] Bipolar Disorder. 15 minute 24/7 [24 hours 7 days per week] wellness checks for safety. 2x daily nursing assessments re [regarding] depression and anxiety. 14 offered recreation groups to increase [his/her] motivation and decrease [his/her] isolation. Medication administration and management."

The intervention statements regarding 15-minute checks, nursing assessment, and medication administration were generic discipline tasks that were not individualized and specifically related to what the staff would do to assist the patient to improve presenting symptoms. The intervention statements regarding weekly therapy and medication management did not include a modality (how the intervention would be delivered- individual or group sessions) and focus of treatment. The medication management intervention also had no frequency of contact listed. Since the goals and interventions were not numbered, it was difficult to determine which goal went with which interventions, especially those interventions related to weekly therapy, process groups, recreation groups, and medication management.

4. Active sample patient B4's MTP dated 11/21/15, had as short-term goals for the problem of "Depressed Mood (depression)": "Take medications as prescribed on a daily basis. Participate in seven (7) recreation groups per week to develop healthy skills to reduce depressed mood and increase socialization. Attend five (5) process and five (5) education groups per week to develop skills to manage depression. Identify three (3) situations causing distress and healthy ways to deal with the stress."

The interventions listed below the short-term goals were: "Medication management/administration" "15 minute checks to ensure safety daily. Process group 5x week. Individual therapy 7x week. Education group 5x week. Vocation group offered 2x day."

The intervention statements regarding medication management, process group, individual therapy, education group, and vocation group did not include a focus of treatment. The intervention statement related to medication management also had no modality listed. The section of the intervention statement related to medication administration and the statement regarding 15 minutes checks were generic discipline tasks and not individualized and specifically related to assisting the patient to improve presenting symptoms. Since the goals and interventions were not numbered, it was difficult to determine which goal went with which intervention.

5. Active sample patient B10's MTP dated 11/28/15, had as short-term goals for the problem of "Major Depressive Disorder": "Attend 4 rec [recreation] groups weekly to increase motivation and decrease isolation. Attend five (5) of the five (5) process groups, six (6) of the seven (7) life skills groups to identify/learn coping skills to reduce depression weekly. Identify three (3) triggers/causes of depression. Identify three (3) coping skills to help reduce depressive symptoms, complete relapse prevention plan."

The interventions listed below the short-term goals were: "Nursing assessments daily x2." "Individual therapy one x per week to learn and implement coping skills. Medication management and administer daily. Attend recreation 4x a week. Attend process group daily to help learn and implement coping skills in a group setting. 15 minute checks 24 hours daily to ensure safety."

The first intervention was a generic nursing task and was not individualized and specifically related to assisting the patient to improve his/her presenting symptoms. Administrating medication and 15 minute checks were also nursing tasks not treatment interventions. The intervention related to medication management and recreation did not include a modality and focus of treatment. Since the goals and interventions were not numbered, it was difficult to determine which goal went with the individual therapy and process group interventions.

6. Active sample patient B13's MTP dated 12/5/15, had as short-term goals for the problem of "Major Depression Disorder": "Patient will verbalize a better understanding of depression and [his/her] depressed symptoms within 2 weeks of treatment. Patient will identify 2 positive socialization activities in order to decrease isolation. Patient will show increased motivation by attending and participating in six (6) groups a day for two (2) weeks. Patient will set up a discharge plan and aftercare services in order to maintain mental health functioning and prevent an increase in depressive symptoms."

The interventions listed below the short-term goals were: "Individual therapy weekly. Process group five days per week. Education group daily. Life skills daily. Aftercare planning weekly. Recreation groups and encourage participation in activities twice daily. Encourage group participation daily. Safety checks every 15 minutes.

The intervention statements regarding individual therapy, process group, education group, life skills, and aftercare planning did not include a focus of treatment based on the patient's presenting symptoms and needs. The intervention statement regarding encouraging group participation and 15-minutes checks were generic discipline tasks and were not individualized and specifically related to assisting the patient to improve his/her presenting symptoms. Since the goals and interventions were not numbered, it was difficult to determine which goal went with which intervention.

7. Active sample patient C2's MTP dated 12/8/15, had as short-term goals for the problem of "Depression": "Take medications as prescribed on a daily basis to help reduce depressed mood. Patient will verbalize a better understanding of depression and his depressed symptoms within two (2) weeks of treatment. Patient will identify two (2) positive socialization activities in order to decrease isolation. Patient will show increased motivation by attending and participating in six (6) groups a day for two (2) weeks. Patient will set up a discharge plan and aftercare services in order to maintain mental health functioning and prevent an increase in depressive symptoms."

The interventions listed below the short-term goals were: "Medication management/administration daily. Process group offered 5x week. Individual therapy 1x week. Education groups offered 5x week. Recreation group offered 2x a day. 15 minute checks to ensure safety."

The intervention statements regarding medication management, process group, and individual therapy, education group, and recreation group did not include a focus of treatment based on the patient's presenting symptoms and needs. The intervention statement regarding medication management also did not include whether it would be delivered in individual or group sessions. The intervention statements regarding medication administration and 15-minutes checks were generic discipline tasks and were not individualized and specifically related to assisting the patient to improve his/her presenting symptoms. Since the goals and interventions were not numbered, it was difficult to determine which goal went with which intervention.

8. Active sample patient C12's MTP dated 12/4/15, had short term goals for the problem "Risk for injury (self-inflicted)": "Pt. will attend Process 5X weekly. Pt. will report no thoughts of self-harm by [no date listed]. Pt. will be able to verbalize thought stopping techniques when thoughts of self-harm occur."

The interventions listed below the short-term goals were: "Medication administration as ordered daily. Pt. on 1:1 observation for safety as ordered by physician. Pt. to meet individually with therapist 2x weekly."

The intervention statements regarding medication administration and patient observation were generic discipline tasks and were not individualized and specifically related to assisting the patient to improve his/her presenting symptoms. The last intervention statement did not include a focus of treatment. Since the goals and interventions were not numbered, it was difficult to determine which goal went with which intervention.

9. Active sample patient C19's MTP dated 12/11/15, had as short-term goals for the problem "Major Depression Disorder": "Patient will identify two (2) ways to improve motivation. Patient will identify two (2) socialization activities to use to decrease isolation. Patient will be free from crying spells for two (2) weeks. Patient will verbalize two (2) ways to improve self-esteem. Patient will set-up aftercare plans including continued mental health services to maintain progress."

The interventions listed below the short-term goals were: "Process groups 5x times per week. Weekly individual sessions. Daily education and life skills groups. Aftercare. Twice daily recreation groups and activities. 15 minute safety checks. Daily encouragement. Twice daily mood assessments. Develop therapeutic relationship. Medication management."

The intervention statements regarding process groups, individual session, education group, life skills groups, aftercare, recreation groups and medication management did not include a focus of treatment based on the patient's presenting symptoms and needs. The intervention statement regarding medication management also did not include a frequency of contact and whether it would be delivered in individual or group sessions. The intervention statements regarding 15-minutes checks, encouragement, mood assessments, and developing therapeutic relationship were generic discipline tasks and were not individualized and specifically related to assisting the patient to improve his/her presenting symptoms. Since the goals and interventions were not numbered, it was difficult to determine which goal went with which intervention.

B. Interview

In an interview on 12/15/15 at 8:30 a.m., the lack of focus of treatment and the difficulty of identifying which goal went with which intervention was discussed with the Director of Nursing. She stated, "We are going to start numbering goals and interventions."




30491

Based upon record review and interview, the Medical director failed to:

I. Ensure that psychiatric assessments included an inventory of the patient ' s assets in a descriptive, not interpretive fashion in seven (7) of eight (8) sample patients (A5, A15, B4, C2, C12 and C19). Failure to describe those personal factors, strengths, and/or attributes of each patient compromises the treatment team's ability to develop goals to meet identified needs of patients and limits the team's ability to engage the patient in treatment based on patient strengths. (Refer to B117)

II. Ensure comprehensive Master Treatment Plans (MTPs) were individualized, behavioral, and specific with all necessary components for eight (8) of eight (8) active sample patients (A5, A15, B4, B10, B13, C2, C12 and C19). Specifically, the MTPs did not include the following:

A. Clearly defined patients' personal strengths/assets and problem statements written in behavioral and descriptive terms for five (5) of eight (8) active sample patients (A15, B4, C2, C12 and C19). (Refer to B119)

B. Observable, patient focused, measurable, and behaviorally stated goals for seven (7) of eight (8) active sample patients (A5, A15, B4, B10, B13, C2 and C12). (Refer to B121)

C. Individualized treatment interventions with a clear description of the patients' specific problems, focus of treatment, and frequency of contact for eight (8) of eight (8) active sample patients (A5, A15, B4, B10, B13, C2, C12, and C19). (Refer to B122)

Failure to develop individualized MTPs with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's treatment needs not being met.




28204

Based on record review and interview, the Nursing Director failed to ensure that nursing interventions on the Master Treatment plans (MTPs) for eight (8) of eight (8) active sample patients (A2, A15, B4, B10, B13, C2, C12 and C19) consistently included nursing interventions with a clear description of the patients' specific problems, focus of treatment, and frequency of contact. Failure to document specific treatment approaches makes it difficult to ensure a consistency in addressing each patient's problems, possibly resulting in prolonged hospitalization for patients.

Findings include:

A. Record Review

1. Hospital policy # SS-058, NUR-3.36, titled "Multidisciplinary Treatment Plan", last revised 4/22/15 stated, "The role of the treatment intervention is to cause its objectives to occur and, if the intervention is appropriate and valid, it can be expected within some set period of time"---"Interventions listed on the 'Individualized Comprehensive Treatment Plan' will reflect individualized interventions/care planning rather include [sic] a list of staff modalities with frequency of the modality, without identification of specific interventions, and specify the focus of individual and group treatment modalities."

2. Active sample patient A2's MTP dated 11/27/15, had the following nursing interventions for the problems of "Bipolar- Mixed, racing thoughts, depression, not feeling safe, isolation": "2x daily nursing to assess depression & [and] anxiety. 15 minute wellness checks for safety. Medication management and administration daily." Depression and safety are vague statements of feelings. The medication management intervention lacked a modality (individual or group sessions) and a focus of treatment.

3. Active sample patient A15's MTP dated 12/12/15, had the following nursing interventions for the problems of "Bipolar Depression, isolated, loss of interest in current activities": "2x daily nursing assessment regarding depression and anxiety," "medication administration and management." The first intervention was a generic nursing task. The second intervention regarding medication management did not include a modality (individual or group sessions) and a focus of treatment.

4. Active sample patient B4, MTP dated 11/21/15, had the following nursing intervention for the problem of "Depressed Mood [depression]": "Medication management/administration." This intervention did not include whether it would be delivered in individual or group sessions and lacked a focus of treatment and frequency of contact. Medication administration was a nursing task and was not individualized and specifically related to what the nurse would do to assist the patient to deal with presenting needs identified regarding medications.

5. Active sample patient B10's MTP dated 11/28/15, had the following nursing interventions for the problem of "Major Depressive Disorder": "Medication management and administration daily." "Nursing assessment daily x2." Neither intervention included a specific focus of treatment.

6. Active sample patient B13's MTP dated 12/5/15, had the following nursing interventions for the problem of "Major Depressive Disorder": "Twice daily mood assessment. Develop a therapeutic relationship. Medication management." The first two interventions were generic nursing tasks that were not specific and individualized intervention statements. The intervention regarding medication management did not include a modality, focus of treatment, or frequency of contact.

7. Active sample patient C2's MTP dated 12/8/15, had the following nursing intervention for the problem of "depression": "Medication management/administration daily." This section of the intervention statement regarding medication management did not include a modality and focus of treatment. The section of the statement regarding administration is a generic nursing task that was not a specific and individualized intervention statement.

8. Active sample patient C12's MTP dated 12/4/15, had the following nursing interventions for the problem of "Risk for injury (self-inflicted)": "Medication administration as ordered daily." "Pt. [patient] on 1:1[one to one] observation for safety as ordered by physician." The first intervention lacked a specific focus. The second intervention was a generic nursing task. It was a not specific and individualized intervention statement regarding what the staff would to do to assist the patient to engage in behavior to keep himself/herself safe.

9. Active sample patient C19's MTP dated 12/11/15, had the following nursing interventions for the problem of "major depressive disorder": "15 minute safety checks. Daily encouragement, twice daily. Mood assessment. Develop therapeutic relationship." These intervention statements were all generic nursing tasks. They were not specific and individualized intervention statements related to what the staff would do to assist the patient to improve his/her presenting problems.

B. Interview

In an interview on 12/15/15 at 8:30 a.m., the lack of focus of treatment on the Master Treatment plans was discussed with the Nursing Director. She did not dispute the findings.




30491

Based upon a review of documents and interviews with staff, the Director of Social Work did not possess a Master's Degree in Social Work (MSW). The facility failed to deploy a staff with a MSW to provide oversight of psychosocial assessments and discharge planning. This failure potentially leads to the provision of clinical social work practices, which may be inadequate for patient needs.

Findings include:

A. In an interview on 12/14/15 at approximately 3:30 p.m., compliance with the psychosocial assessment was discussed with the Director of Social Services. He acknowledged that License Professional Counselors were authorized to complete the psychosocial assessment. He reported that he was a Licensed Professional Counselor and did not have a Masters in social work. When asked who provided oversight for the psychosocial assessment and discharge planning he stated, "I do." He further stated that the facility had one staff with a Master's Degree of Social Work (MSW). However, this person did provide the oversight because of Ohio's licensure requirements.

2. In an interview on 12/15/15 at 8:30 a.m. with the Administrator, Director of Social Work, and Director of Nursing, the oversight for clinical social work practice was discussed. The Administrator acknowledged that the hospital did not meet CMS requirement. She stated, "If we meet the CMS requirements by having our MSW supervise our staff who don't have a MSW, we would then violate Ohio's requirements. We can't ask her [referring to the social worker with the MSW] to do that." The Administrator reported that they thought this requirement had been waived but they did not have anything in writing.




28204