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Based on record review and staff interview, the facility failed to provide comprehensive Master Treatment Plans (MTPs), that were individualized and included all required components for eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8). Failure to develop individualized MTPs by the team with all the required components hampers the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's treatment needs not being met.

Findings include:

A. Record Review

Review of the MTPs of the eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8) revealed that the facility used an electronic medical record program that included drop down screens with pre-written long-term goals, short-term goals (called objectives in this facility), and staff interventions that failed to:

1. Include individualized long and short-term objectives which stated what the patient would do to lessen the severity of problems identified for eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8). The treatment plans contained long and short term objectives that were vague, and non-measurable. Several objectives were staff oriented rather than patient oriented. Additionally, some objectives were identical for patients with different diagnoses and/or different manifestation of symptoms. Failure to identify individualized goals potentially hampers the treatment team's ability to determine whether the treatment plan is effective or if it needs to be revised. (Refer to B121)

2. Include individualized and specific treatment modalities to assist patients to accomplish treatment goals and/or improve presenting symptoms of eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8). Instead, MTPs included generic and routine discipline functions written as treatment interventions. Many intervention statements also failed to include how the intervention would be delivered (group or individual sessions). In addition, because frequency of contact and the staff responsible for implementing interventions were listed in a separate section of the MTP, it was difficult to determine the frequency of contact for each intervention listed. These failures also potentially results in inconsistent and/or ineffective treatment. (Refer to B122)

B. Interviews

1. In an interview on 6/10/14 at 10:40 a.m., the non-measurable short and long-term objectives were discussed with RN #1. She stated, "We don't develop them (objectives) ourselves. We select them from a list of choices already in the pre-written treatment plan forms on the computer."

2. During interview on 6/10/14 at 7:30 a.m., the Director of Quality Improvement stated that they primarily revised the objectives in the electronic medical record and admitted that they did not spend as much time revising the staff intervention section of the electronic medical record.