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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.

Based on record review and interview, the facility failed to provide Master Treatment plans (MTPs) that included short/long-term goals (called objectives in this facility) stated in measurable terms for eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8). In addition, some of the goals were very vague and/or staff goals (what the staff wanted the patient to do), not patient goals. These deficient practices hamper the ability of the treatment team to determine if the goals are effective based on changes in patient behavior or need to be revised.

Findings include:

A. Record Review

1. Facility policy number PC 108, titled "Multidisciplinary Initial Treatment Plan and Update", last revised May 2014, stated: "An individualized treatment update is developed for each patient based on needs identified during the admission assessment."...."At a minimum, the attending physician, nursing, and social work contribute to the patient's care plan, identify initial problems that are specific to the reason for hospitalization (done by the RN within eight hours of admission and the other disciplines next working day)."..."...formulate a long-term outcome that describes behavior sought in order to be discharged. Goals should be based on patient's identified strengths and disabilities, formulate short-term measurable objectives for each active problem." Although the policy now included an attachment regarding treatment goals, this policy continued to provide insufficient information to guide clinical staff when formulating treatment goals, such as goals that were patient focused based on specific behaviorally stated presenting symptoms.

The electronic medical records [EMR] provided pre-written short and long term goals (called objectives in this facility) and interventions based on specific identified problems. The staff selected a problem then selected goals and interventions from a list of generic options provided by the program. Many of these pre-written objective statements were not measurable, not written in descriptive behavioral terms, and/or was staff oriented rather than patient focused.

2. Active sample patient A1, MTP dated 6/5/14, had as a problem "thought disorder." Manifestation: "Thought disorder as evidenced by unusual perceptual experiences; pt [patient] reporting AH [auditory hallucinations] 'the voice is in charge of me'." The long-term objectives were, "Patient will be free from hallucinations prior to discharge", and "Patient will be free from delusions prior to discharge." The short-term objective was, "Patient will take all medication consistently over 3 days." The long-term objectives and the short-term objective were not measurable. These objectives were staff objectives which stated what staff wants the patient to achieve instead of direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or eliminate the presenting problem(s). For the problem "Potential for self-directed injury", the manifestation was, "Superficial cutting for temporary relief of intense feelings, hx [history] of trying to jump off [sic] a window." The non-measurable long-term objectives were: "The patient will be free of suicidal ideation, thought, and feelings, and will develop new alternatives to cope with the conditions that contributed to them. The patient will learn coping skills that reduce the chance of relying on self-destructive behavior." The objectives did not include behaviors to describe how staff would measure thoughts and feelings. Without describing specific behaviors, it would be difficult to determine how staff would tell if the patient had learned something. The short term objective was, "Within 3 days patient will maintain safety and self-harm [sic]." This was a vague statement in that it did not describe what "will maintain self-harm" meant.

3. Active sample patient A6, MTP dated 6/5/14, had as a problem "depression." Manifestation: "Suicidal ideation." The short-term objective was, "Patient will get out of bed without prompting over 3 consecutive days." This objective was a staff, not patient one. The specific behavior that the patient was exhibiting was not described under the problem of "depression." For the problem of "suicide," the manifestation was "suicide risk as evidenced by suicidal thoughts with plan report [sic] states pt said [s/he] wanted to drown [his/herself]." The non-measurable long-term objective was "patient will be free of suicidal ideations by discharge." For the problem of "Suicide," The non-measurable long term objective was, "Patient will be free of suicidal ideations by discharge."

4. Active sample patient B1, MTP dated 6/5/14, had as a problem "thought disorder." The non-measurable long-term goals were: "Patient will be free from hallucinations prior to discharge. Patient will be free from delusion prior to discharge."

5. Active sample patient B12, MTP dated 6/5/14, had as a problem "suicide."
Manifestations: "Suicidal risk as evidenced by history of suicide attempt. Suicide risk as evidenced by suicidal thoughts with plan overdose on pills. Suicide risk as evidenced by command hallucinations to hurt self." The latter manifestation was difficult to measure. A non-measurable long-term objective was, "Patient will be free of suicidal ideations by discharge."

6. Active sample patient C6, MTP dated 6/5/14, had as a problem "thought disorder."
Manifestation: "Thought disorder as evidenced by odd or bizarre behavior." Because the problem statement was vague and absence of a description of specific behaviors to observe, the objectives were also vague and non-measurable. The non-measurable long-term objective was, "Patient will no longer be functionally impaired by delusions prior to discharge." This was another vague statement. The specific behaviors to be observed were not described.

7. Active sample patient C8, MTP dated 6/5/14, had as a problem "mania." Manifestation: "Provocative, intrusive, and aggressive behavior." The short-term objective for mania was, "Patient will request coping tools from unit staff when feelings begin to escalate." This staff, not patient objective, was vague and did not contain a description of "coping tools." For problem "Aggression/Violence," the staff oriented short term objective was, "Patient will outline in crisis plan the specific behaviors to prevent escalation to verbal outbursts or violence."

8. Active sample patient D7, MTP dated 6/5/14, had as a problem "depression." Manifestation: The long-term objectives were: "Patient will perform ADLs [activities of daily living] without prompting/supervision by discharge." "Patient will be able to control crying episodes prior to discharge." The first objective was a staff, not patient objective. The second objective was not measurable.

9. Active sample patient D8, MTP dated 6/4/14, had as a problem "thought disorder." Manifestation: "Thought disorder as evidenced by appearing to respond to hallucinations. Thought disorder as evidenced by odd or bizarre behavior. Thought disorder as evidenced by inappropriate affect, medical history: paranoid schizophrenia." The manifestations did not describe specific behaviors. The non-measurable long-term objective was, "Patient will be free from hallucinations prior to discharge." The short-term objective for thought disorder was, "Patient will take all medications consistently over 3 days." This was a staff, not patient objective.

B. Interviews

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 ourselves. We select them from a list of choices already on the pre-written treatment plans on the computer."

Based on observation, record review and interview, the facility failed to consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8). Specifically, interventions were stated as generic monitoring and discipline functions written as treatment interventions to be performed by clinical staff. MTPs also failed to consistently state the frequency of contact, specific focus for interventions, and whether interventions would be delivered in group or individual sessions. In addition, all patients were expected to attend all the groups listed on each unit's schedule. However, the MTPs did not include groups attended by patients from these unit schedules. These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

I. Failure to include individualized treatment interventions on MTPs

A. Policy Review

Facility policy number PC108, titled "Multidisciplinary Initial Treatment Plan and Update," last revised May 2014, stated: "At minimum the attending physician, nursing, and social work [sic] contribute to the patient's care plan"..."Describe the multi-disciplinary modalities that are utilized to assist the patient in attaining their goals." Although, this policy now contained more information in an attachment to the policy regarding writing measurable treatment goals, the policy continued to have insufficient information available to guide clinical staff when writing treatment intervention statements.

B. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (6/5/14), A6 (6/5/14), B1 (6/5/14), B12 (6/5/14), C6 (6/5/14), C8 (6/5/14), D7 (6/5/14), and D8 (6/4/14) This review revealed that the MTPs had the following routine and generic statements (monitoring, assessing, and evaluating tasks) and/or other generic discipline functions written as treatment interventions to be delivered by the psychiatrist (MD), registered nurse (RN), social worker (SW), and activity therapist (AT) [called group therapists by the facility]. Additionally, many treatment plans did not include: 1) how the intervention would be delivered (individual or group sessions); 2) the frequency of contact and/or 3) the focus or purpose of treatment related to the patient's presenting and behaviorally descriptive symptoms. Some interventions were identical or similarly worded.

1. Active sample patient A1 had a problem of "Thought Disorder...The voice is in charge of me." Generic staff interventions were:

"Psychiatrist will prescribe and monitor medications..." This statement was generic and not individualized. The psychoeducational part of this intervention statement did not include a frequency of contact.

"Nursing staff will reinforce medication education when administering medication as scheduled." "Nursing will evaluate medication regime effects and benefits [sic] by monitoring patients behaviors." These statements were not individualized and were routine nursing functions that would be provided any patient regardless of presenting symptoms. This statement did outline specific treatment intervention(s) to assist this patient to accomplish his/her treatment goals.

"Social work will provide appropriate discharge/aftercare plans with patient, family, S.O. [significant others] or other supports system input." This intervention was not individualized and was a social worker task rather than specific interventions related to this patient's failed aftercare plans such as action that the patient could use to prevent readmission and actions the patient could use to eliminate or lessen the magnitude of symptoms that resulted in hospitalization.

For the problem of "Potential for self-directed injury...hx [history] of trying to jump off a window," the following interventions did not include a frequency of contact.

"Nursing staff will teach patient behavior self control and coping skills to prevent self injury." "Nursing staff will educate patient on effects of medication and the importance of meciation [sic] compliance." These interventions did not include a frequency of contact or whether the interventions would be delivered in group or individual sessions.

2. Active sample patient A6 had the following generic staff interventions for the problem of "Depression...Manifestations - Suicidal ideation":

"Nursing staff will initiate interactions with patient and encourage verbalization of feelings every shift." This statement was not individualized and did not outline specific treatment interventions(s) to assist this patient to accomplish his/her treatment goals. This statement was actually a generic and routine nursing function written as a treatment intervention and would be provided for any patient regardless of presenting symptoms.

"Social Worker will meet with patient and family to identify conflicts contributing to depression." This statement was a generic routine social worker function and did not include whether the interventions would be delivered in group or individual sessions.

There were no psychiatrist or activity therapy interventions for this problem.

For the problem of "Suicide...Manifestations - Suicide risk as evidenced by suicidal thoughts with plan report states pt [patient] said (s/he) wanted to drown (him/herself)," the generic routine statement written as a treatment intervention was:

"Social worker will assist patient and support systems as appropriate in developing a safety plan." This statement was not individualized and did not include a frequency of contact or delivery method (group or individual sessions).

There were no interventions for this problem statement included for the psychiatrist and registered nurse.

3. Active sample patient B1 had the following generic staff interventions for the problem of "thought disorder... Manifestations - Thought disorder as evidenced by making paranoid statements..."

"Nursing will evaluate medication regime effects and benefits [sic] by monitoring patients [sic] behaviors." This statement was not individualized and did not outline specific treatment interventions(s) such as patient teaching regarding medication that would assist this patient to accomplish his/her treatment goals. This statement was actually a generic and routine nursing function written as a treatment intervention and would be provided for any patient regardless of presenting symptoms.

"Group therapist [AT] will involve patients in activities to assist in developing social interests and leisure activities to decrease [sic] social isolation." This intervention was not individualized and did not include the specific activity therapy groups relevant to this patient's needs.

"Psychiatrist will prescribe and monitor medications..." "Psychiatrist will evaluate medication regime, effects, and benefits [sic] by monitoring patients [sic] behaviors." These were generic and routine MD functions rather than specific individualized interventions that would assist this patient, such as patient teaching related to the specific medications prescribed, and actions the patient could use to eliminate or lessen the magnitude of symptoms that resulted in hospitalization.

For the problem of "Discharge Planning....Manifestations - Failed discharge/aftercare plan with readmission," the generic statements were:

"Social Worker will coordinate patient's return to community with patient providers and patient prior to discharge." "Social Worker will contact and coordinate discharge planning with patient's family and support systems within 48 hours of discharge." These interventions were not individualized and were social worker functions rather than specific interventions related to this patient's failed aftercare plans, such as action that the patient could use to prevent readmission and actions the patient could use to eliminate or lessen the magnitude of symptoms that resulted in hospitalization.

4. Active sample patient B12 had the following generic staff interventions for the problem of "Depression...Manifestations - Hopelessness Suicidal ideation Depressed feeling [sic]":

"Nursing staff will encourage attendance in community meetings and groups daily." "Nursing staff will initiate interactions with patient and encourage verbalization of feelings every shift." These statements were generic and routine nursing functions that would be provided for any patient regardless of the patient's presenting symptoms.

"Group therapist [AT] will provide groups to help the patient better understand the depressive patterns in the patients [sic] life and social interactions, and to provide support from others to combat depressed mood." This intervention was not individualized and did not include the specific activity groups relevant to this patient's needs.

"Attending will evaluate patient medication regime and adjust medications with input from patient." This statement was a generic and routine MD function that would be provided regardless of the patient's presenting symptoms.

For the problem of "suicide...Manifestations - Suicide risk as evidenced by suicidal attempt. Suicide risk as evidence by suicidal thoughts with plan OVERDOSE ON PILLS. Suicide risk as evidence by command hallucinations to hurt self," the generic statements written as treatment interventions were:

"Group therapist [AT] to provide therapeutic groups to assist patient in coping and suicidal thinking, improve self-esteem, and develop hope and future plans." This intervention was not individualized and did not include the specific activity therapy groups relevant to this patient's needs.

"Attending (physician) will regulate medication based during morning rounds based on patient verbalization of feelings and staff observation." This was a generic and routine MD function rather than specific individualized interventions related to this patient's presenting problems, such as patient teaching related to the specific medications prescribed and actions the patient could use to eliminate or lessen the magnitude of symptoms that resulted in hospitalization.

"Nursing staff will prompt patient to complete activities of daily living while hospitalized." "Nursing will maintain patient on appropriate precaution level (specify) [sic] to provide a safe environment." These interventions written as treatment interventions were generic routine nursing functions that would be provided for any patient regardless of the patient's presenting symptoms.

For the problem of "Medication Noncompliance... Manifestations - PT [Patient] reports not taking medications as prescribed," the treatment intervention was:

"Nursing will encourage pt [patient] to attend Medication Group 3x per week. Nursing will evaluate compliance every shift." Encouraging group attendance and evaluating compliance were routine nursing functions. This intervention did not include a focus for the medication group such as assisting the patient to understand the benefits of continuing to take medications once discharged.

For the problem of "Discharge Planning...Manifestations - Failed discharge/aftercare plan with readmission," the generic staff interventions were:

"Social Worker will coordinate patient's return to community with patient providers and patient prior to discharge." "Social Worker will assist patient in identifying AA/NA meeting with reasonable travel distance in their [sic] community prior to discharge." These interventions were not individualized and were social worker functions rather than specific interventions related to this patient's failed aftercare plans such as action that the patient could use to prevent readmission and actions the patient could use to eliminate or lessen the magnitude of symptoms that resulted in hospitalization.

5. Active sample patient C6 had the following generic interventions for the problem of "Thought Disorder... Manifestations - Thought disorder as evidenced by odd or bizarre behavior."

"Psychiatrist will evaluate medication regime, effects, and benefits by monitoring patients [sic] behaviors." This statement was a generic and routine MD function that would be provided regardless of the patient's presenting symptoms.

"Group Therapists [AT] will provide cognitive groups to assists patients [sic] in developing [sic] to address relapse prevention." "Group Therapist will provide cognitive groups to assist patients [sic] in developing social skills." These interventions were not individualized and did not include the specific cognitive groups relevant to this patient's needs. In addition, these interventions were not congruent with the short term objective identified as "Patient will be able to verbalize importance of adherence to medication regime, thereby controlling symptoms within 5 days." After reviewing the description of groups submitted by the AT 1, it was difficult to determine how which cognitive groups would facilitate the patient to accomplish the short term objective identified on the MTP.

"Nursing staff will teach TIC [sic] behavioral self-control and coping skills to prevent outburst and improve impulse control." This intervention did not include a frequency of contact or whether it would be delivered in group or individual sessions. "Unit staff will orient patients [sic] to unit expectations, reinforce expectations throughout hospital stay to provide a calming unit." This was a routine nursing task that would be provided regardless of the patient's presenting symptoms.

For the problem of "Mania... Manifestations - pressured speech, hx [history] bipolar," the generic staff interventions wee:

"Attending (physician) will work with patient and staff to evaluate the effectiveness of medications and adjust dosage based on observable behaviors." "Attending will evaluate patient during morning rounds for reduction in behaviors requiring re-hospitalization." These interventions written as treatment intervention were not individualized and were actually routine MD tasks that would be provided any patient regardless of the patient's presenting symptoms.

6. Active sample patient C8 had the following generic staff interventions for the problem of "Aggressive/Violence...Manifestations - Striking a Peer in Group Home Residence":

"Social worker will develop discharge plan with patient to minimize and prevent episodes of acting out behavior that would lead to readmission." This intervention did not include a frequency of contact and whether the intervention would be conducted in group or individual sessions.

"Attending (physician) will monitor patients [sic] behavioral control during morning rounds and adjust medications based on patient behavior and staff observations." This was a generic and routine MD function rather than specific individualized interventions related to this patient's presenting problems, such as patient teaching related to the specific medications prescribed and behavioral control techniques the patient could use to eliminate or lessen the magnitude of symptoms that resulted in hospitalization.

"Group Therapist [AT] will work with patient during group to develop leisure activities and coping skills for discharge." "Group Therapist will assist patient in reaching activity goals as defined in the group therapy update." These interventions were not individualized and did not include the specific activity groups relevant to this patient's needs.

7. Active sample patient D7 had the following generic staff interventions for the problem of "Substance Abuse... Manifestations - "Excessive use of alcohol and marijuana impairing functioning in daily life."

"Nursing staff will provide 1:1 discussions daily on recovery goals." This intervention did not include the specific focus of the interventions that was related to the patient's presenting symptoms and level of functioning. "Nursing staff will utilize withdrawal assessment tools (COWS [Clinical Opiate Scale], CIWAS [Clinical Institute Withdrawal of Alcohol Scale] to assess the patient level of withdrawal [sic] from opioids and alcohol." The use of clinical assessment scales by nurses was a generic and routine nursing task function rather than an individualized and specific intervention related to this patient's level of functioning associated with alcohol abuse as identified in the "Multidisciplinary Assessment Summary."

"Social Worker will discuss relapse prevention with patient." This intervention did not include the frequency of contact or how the intervention would be delivered (group or individual sessions).

"Group Therapist will assist patient in reaching activity [sic] goals as defined in the group therapy update." "Group Therapist will provide relapse prevention education in groups daily." These interventions were not individualized and did not include the specific activity groups relevant to his patient's needs or frequency of contact for each group in the first group therapist intervention mentioned above.

"Psychiatrist will monitor s/s [sign/symptoms] of withdrawal and effects of medications for detox during morning rounds." Monitoring signs and symptoms of withdrawal and effects of medications was a generic and routine MD function rather than specific individualized treatment interventions related to this patient's needs, such as patient teaching related to the alcohol abuse, specific medications prescribed, and strategies the patient could use to eliminate or lessen the magnitude of symptoms that resulted in hospitalization. This same intervention was identical or similarly worded on the MTP of Patient D8.

For the problem of "Depression...Manifestations - Depressed feeling," the generic interventions were:

"Attending (physician) will evaluate patient medication regime and adjust medications with input from patient." Evaluating and adjusting medications were generic and routine MD tasks that would be provided regardless of the patient's presenting symptoms.

"Nursing will educate patient on expected therapeutic effects of medication, know side effects, and importance of compliance with medication regime." This intervention did not include a frequency of contact, a delivery method (group or individual sessions) and was not individualized to include specific anti-depressive medication(s) to be taught, and compliance issues such as stopped taking medication because of side effects, not able to obtain medications due to financial and/or transportation problems, etc. "Nursing will reinforce medication education while administering medications scheduled." This intervention was a generic and routine nursing function that would be performed for any patient receiving medications.

"Group therapist [AT] will teach TIC [sic] coping skills in provided groups." "Group Therapist will provide groups to help the patient better understand the depressive patterns in the patients [sic] life and social interactions, and to provide support from others to combat depressed mood. These interventions were not individualized and did not include the specific activity therapy groups relevant to this patient's needs or the frequent of contact for each group.

"Social Worker will meet with patient to identify conflicts contributing to depressions." This intervention was not individualized and was a social worker function rather than a specific intervention related to this patient's manifestation of depression and did not include actions to be taken by social work staff to assist the patient to eliminate or lessen the magnitude of symptoms that resulted in hospitalization. This same intervention was identical or similarly worded on the MTP of Patient A6.

8. Active sample patient D8 had the following generic staff interventions for the problem of "Substance Abuse...Manifestations - BAL 324 [sic]"

"Nursing staff will encourage patient to attend substance abuse groups daily." This was a generic and routine nursing function rather than an individualized intervention related to this patient's level of functioning associated with alcohol abuse as identified in the "Multidisciplinary Assessment Summary."

"Social Worker will discuss relapse prevention with patient." This intervention did not include the frequency of contact, the focus of the intervention related this patient's specific manifestation of relapse, nor how the intervention would be delivered (group or individual sessions).

"Group Therapist will assist patient in reaching activy [sic] goals as defined in the group therapy update." This intervention was not individualized and did not include the specific activity groups relevant to this patient's needs. This same intervention was identical or similarly worded on the MTPs of Patients C8 and D7.

"Psychiatrist will monitor s/s [sign/symptoms] of withdrawal and effects of medications for detox during morning rounds." Monitoring signs and symptoms of withdrawal and effects of medications was a generic and routine MD function rather than specific individualized treatment interventions related to this patient's needs, such as patient teaching related to the alcohol abuse, specific medications prescribed, and strategies the patient could use to eliminate or lessen the magnitude of symptoms that resulted in hospitalization.

For the problem of "Thought Disorder...Manifestations - Thought disorder as evidenced by appearing to respond to hallucinations. Thought disorder as evidenced by odd or bizarre behavior. Thought disorder as evidenced by inappropriate affect, medical history: paranoid schizophrenia," the generic interventions were:

"Psychiatrist will prescribe and monitor medications, and provide psychoeducation to patient regarding their purpose, use, and side-effects of medication during morning rounds." Prescribing and monitoring medications were generic and routine MD functions. The psychoeducation mentioned in this intervention did not include a delivery method (group or individual sessions).

"Social Worker will provide appropriate discharge aftercare plans with patient." This was a generic and routine Social Worker task that would be provided any patient regardless of the patient's presenting symptoms.

"Group therapist will provide cognitive groups to assist patients [sic] in developing to address relapse prevention." "Group therapist will involve patient in activities to assist in developing social interests and leisure activities to decrease social isolation." These interventions were not individualized and did not include the specific activity groups relevant to this patient's needs. These same interventions were identical or similarly worded on the MTP of Patient B1.

B. Interviews

1. In an interview on 6/10/14 at 7:30 a.m., the generic interventions on the MTPs were discussed with the Director of Nursing. She acknowledged that the interventions were generic and routine discipline functions on the MTPs.

2. In an interview on 6/10/134 at 1:40 p.m. with AT #1, the MTPs were discussed. AT #1 agreed that interventions were not specific and were generalized statements for treatment.

3. In an interview on 6/11/14 at 10:00 a.m. with RN #2, MTPs for Patients C6, C8, D7, and D8 were discussed. RN #2 acknowledged that generic and nursing interventions were on the treatment plans. RN #2 admitted the "daily" frequency of contact identified on the MTPs for nursing interventions did not correlate to what was actually done by nursing staff. RN #2 also acknowledged that the Medication Group conducted by registered nurses was not included on the MTP despite the expectation that all patients receiving medication were to attend this group.

4. During interview on 6/10/14 at 1:10 p.m., the generic interventions on the MTPs were discussed with the Medical Director. He admitted that the reason for this was because of the pre-written plans already in the computer program. "The selections of goals and interventions are right there for the staff to select from."


II. Failure to include groups attended by patients on MTPs

A. Observation

1. During observation in the Dayroom on 6/9/14 at 10:45 a.m., Patients D7 attended a group listed on the "Inpatient Groups - Dual Diagnosis Unit" Scheduled as "Group Therapy." The topic of the group was stages of recovery. At 3:00 p.m. on 3 South Unit, Patients C6 and C8 attended a group led by the AT #2. The topic of this group session was music therapy and Dialectical Behavioral Therapy.

2. During observation in the Group Room on 6/10/14 at 10:35 a.m., Patients C6 and C8 attended a group led by AT #1 and listed on the "Inpatient Groups - 3 South Unit" Scheduled as "Group Therapy." The topic of this group session was a general discussion regarding feelings.

B. Record Review

1. A review of the medical record showed that none of the groups attended by patients on 6/9/14 and 6/10/14 was included on the following patients' MTPs (dates of plans in parenthesis: C6 (6/5/14), C8 (6/5/14), and D7 (6/5/14).

2. A review of the group schedules for the 2 South, Women, Dual Diagnosis and 3 South Units revealed that there were four active treatment groups that all patients were expected to attend Monday through Friday and three active treatment groups offered on the weekends.

C. Interviews

1. During interview on 6/9/14 at 11:20 a.m. with AT #1, the group schedule was discussed. AT #1 acknowledged that the group she conducted was not included on the MTPs. AT stated that a general statement about activity therapy groups was included on the MTPs but not each specific group.

2. In an interview on 6/10/14 at 7:30 a.m. with the Director of Quality Improvement, she acknowledged that specific groups attended by patients were not included on the MTP. She stated that she was working on a way to include these groups on MTPs with name of the group, focus of intervention, and frequency of contact for each discipline conducting groups.







07814

Based on record review and interview, the facility failed to consistently develop for eight (8) of eight (8) active sample patients (A5, A7, A10, B3, B4, B12, C1 and C6) Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of each patient. Interventions were stated as generic monitoring and discipline functions to be performed primarily by physicians, nurses and social workers. In addition, the plans failed to consistently state how these generic interventions would be delivered and how often they would be delivered. The interventions were actually discipline tasks written as treatment interventions. All patients were expected to attend all the groups listed on the unit schedule. However the MTPs did not include all the groups from the schedule. These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Facility policy number PC108, titled "Multidisciplinary Initial Treatment Plan and Update," last revised "2/10," stated: "At minimum the attending physician, nursing, and social work [sic] contribute to the patient's care plan"..."Identify the multi-disciplinary staff/interventions that will assist the patient in meeting the short/long term outcomes." This policy did not provide sufficient information to guide clinical staff when writing treatment modalities.

2. The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (updated 2/20/14), A7 (2/22/14), A10 (2/20/14), B3 (2/20/14), B4 (2/21/14), B12 (2/22/14), C1 (2/20/14, and C6 (2/18/14). This review revealed that the MTPs had the following routine generic discipline functions written as treatment interventions to be delivered by the psychiatrist, registered nurse (RN), social worker (SW). Additionally, many treatment plans did not include: 1) how the intervention would be delivered (individual or group sessions); 2) the frequency of contact and/or 3) the focus or purpose of treatment related to the patient's presenting and behaviorally descriptive symptoms. Many interventions were identical or similarly worded.

a. Active sample patient A5 had a problem of "suicide." Generic staff interventions were:

"Nursing staff will maintain patient on appropriate level, i.e. 15 min [minute] suicide checks, 1:1 observation, day hall observation, to provide a safe environment and decrease suicide attempts."

"Psychiatrist will evaluate, prescribe, and monitor medications for suicidal depression."

"Social work will work with the patient and any outpatient supports to address this issue."

These statements written as treatment interventions were routine functions each staff member would do regardless of the patient's specific problems.

For the problem of depression, the generic staff interventions were as follows:

"Nursing staff will encourage attendance in community meetings, and groups daily."

"Psychiatrist will evaluate, prescribe, and monitor medications for depression."

"Social work will work with the patient and any outpatient supports to address this issue."

Most of the interventions lacked frequency or focus.

b. Active sample patient A7 had the following generic staff interventions for the problem of "aggression, violence":

"Nursing staff will provide individual medication education everyday."

"Psychiatrist will prescribe and monitor medications and provide psychoeducation to patient regarding their purpose, effects, and use."

These statements did not include whether they would be delivered in group or individual sessions and most lacked specific focus.

- For the problem of "depression," the generic staff interventions were:

"Nursing will encourage and supervise ADLs [activities of daily living] daily. Nursing staff will provide individual medication education to revise benefits and side effects of medications."

"Psychiatrist will evaluate, prescribe, and monitor medications for depression."

Most of these interventions lacked frequency.

- For the problem of "suicide," the generic interventions were:

"Nursing staff will maintain an appropriate precaution level; i.e. 15 minutes suicide checks."

"Psychiatrist will evaluate, prescribe, and monitor medications for suicide depression."

The latter intervention also lacked frequency.

c. Active sample patient A10 had the following generic staff interventions for the problem of " thought disorder " :

"Social worker will provide 1:1 reality-oriented counseling ..., structuring patient use of aftercare services and give the patient a place to discuss feelings and concerns."

"Psychiatrist will prescribe and monitor medications."

These interventions also lacked frequency of contact and delivery method.

- For the problem of "mania," the generic staff interventions were:

"Nursing staff will educate on rational benefits and side effects of medications."

"Psychiatrist will prescribe and monitor medication daily to reduce behavior."

The nursing interventions lacked frequency of contact and delivery method.

d. Active sample patient B3 had the following generic staff interventions for the problem of "thought disorder":

"SW [social worker] will meet with pt [patient] daily, monitor mood and ms [mental status], rounds, and collaborate with collaterals, groups."

"Group therapist will involve patient in activities in order to help patient develop some interests and leisure activities, and to deal with social isolation."

"Psychiatrist will prescribe and monitor medications, and provide psychoeducation to patient regarding their purpose, use, and side effects of medication." No modality (individual or group session) was included. The latter two (2) interventions also lacked frequency of contact.

e. Active sample patient B4 had the following generic interventions for the problem of "suicide."

"Nursing staff will encourage patient to verbalize feelings and thoughts and alternatives about suicide." No frequency was included.

"SW will meet with pt. [Patient] daily, monitor mood and ms [mental status], rounds, collaborate with collaterals, groups, treatment updat

Based on interview and document review, the Medical Director failed to:

I. Ensure that psychiatric evaluations were reviewed by a physician for two (2) of eight (8) active sample patients (B3 and B12). Instead, psychiatric evaluations for these patients were completed by an Advanced Practice nurse without documented physician review. This potentially results in the failure to have patient care provided under the direction and supervision of a physician. (Refer to B110)

II. Ensure that psychiatric evaluations included a general medical history of inter-current medical problems for two (2) of eight (8) active patients (B4 and C1). This deficiency potentially results in the inability to assess the impact of an acute or chronic medical condition on current psychiatric presentation. (Refer to B112)

III. Ensure that psychiatric evaluations included an inventory of specific patient assets for eight (8) of eight (8) sample patients (A5, A7, A10, B3, B4, B12, C1, and C2). The failure to identify patient assets potentially impairs the treatment team's ability to choose treatment modalities that best utilize the patient's strengths. (Refer to B117)

IV. Provide Master Treatment plans that included patient-related short and/or long-term goals (called objectives in this facility) stated in measureable terms for eight (8) of eight (8) active sample patients (A5, A7, A10, B3, B4, B12, C1, and C6). In addition, some of the goals were staff goals, not patient goals. Many of the problems listed on the plan were not clearly stated. These deficient practices hamper the ability of the treatment team to provide goal directed treatment to determine the effectiveness of interventions based on changes in patient behaviors. (Refer to B121)

V. Provide 7 of 8 active sample patients (A5, A7, A10, B3, B12, C1, and C6) with Master Treatment Plans (MTPs) which included individualized interventions that stated specific treatment modalities, with a frequency and focus of treatment to be delivered by physicians. Instead, the MTPs included routine physician functions written as treatment interventions. This deficiency results in the facility not clearly delineating the role of physicians in the treatment of patients.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (updated 2/20/14), A7 (2/22/14), A10 (2/20/14), B3 (2/20/14), B4 (2/21/14), B12 (2/22/14), C1 (2/20/14, and C6 (2/18/14). This review revealed that the MTPs had the following routine generic psychiatrist functions written as treatment interventions. Additionally, many treatment plans did not include: 1) how the intervention would be delivered (individual or group sessions); 2) the frequency of contact and/or the focus of treatment. Many interventions were identical or similarly worded.

1. Active sample patient A5, MTP, had a problem of "suicide." Generic physician ntervention was:

"Psychiatrist will evaluate, prescribe, and monitor medications for suicidal depression."

This statement written as a treatment intervention was generic and a routine function that the psychiatrist would do regardless of the patient's specific problems.

For the problem of depression, the generic physician intervention was as follows:

"Psychiatrist will evaluate, prescribe, and monitor medications for depression."

2. Active sample patient A7, MTP, had the following generic physician intervention for the problem of "aggression, violence":

"Psychiatrist will prescribe and monitor medications and provide psychoeducation to patient regarding their purpose, effects, and use." The latter part of this statement did not include frequency of contact or the delivery method.

- For the problem of "depression," the generic physician intervention was:

"Psychiatrist will evaluate, prescribe, and monitor medications for depression."

- For the problem of "suicide," the generic intervention was:

"Psychiatrist will evaluate, prescribe, and monitor medications for suicide depression."

3. Active sample patient A10, MTP, had the following generic physician intervention for the problem of "thought disorder":

"Psychiatrist will prescribe and monitor medications."

- For the problem of "mania," the generic physician intervention was:

"Psychiatrist will prescribe and monitor medication daily to reduce behavior."

4. Active sample patient B3, MTP, had the following generic physician intervention for the problem of "thought disorder":

"Psychiatrist will prescribe and monitor medications, and provide psychoeducation to patient regarding their purpose, use, and side effects of medication." No modality (individual or group session) was included.

5. Active sample patient B12, MTP, had the following generic physician intervention for the problem of "manic":

"Psychiatrist will prescribe and monitor medications daily to reduce manic behavior."

6. Active sample patient C1, MTP, had the following generic physician intervention for the problem of "substance abuse":

"Psychiatrist will provide order [sic] appropriate detoxification protocol. Psychiatrist will educate on relationships between substance abuse and physical/mental illness."

7. Active sample patient C6, MTP, had the following generic physician intervention for the problem of "depression":

"Psychiatrist will order appropriate detoxification protocol."

B. Interview

During interview on 2/25/14 at 4:10 p.m., the Master Treatment plans were reviewed with the Medical Director. He agreed that the interventions contained clinical task such as prescribing medications rather than individualized treatment interventions based on the patient's presenting symptoms. He acknowledged that the intervention did not contain the modality used (individual or group session) to discuss the benefits, side effects, etc. of primary psychotropic medication(s) prescribed.

VI. Provide active treatment, including purposeful alternative interventions for four (4) of eight (8) active sample patients (A5, B3, C1, and C6). Although the treatment plans for these patients included multiple group therapies, patients regularly and repeatedly did not attend groups. They spent many hours without any structured activity and occupied their time by sleeping or wandering around the hallways. Despite inconsistent or lack of regular attendance in groups, master treatment plans were not revised to reflect individual treatment sessions instead of group treatment. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125)





07814

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

1. Provide comprehensive Master Treatment Plans (MTPs) that were individualized and included all required components for eight (8) of eight (8) active 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. (Refer to B118)

2.. Ensure that MTPs included short/long-term goals (called objectives in this facility) were stated in measurable terms for eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8). In addition, some of the goals were staff objectives (what the staff wanted the patient to do) not patient objectives. These deficient practices hamper the ability of the treatment team to determine if the objectives are effective based on changes in patient behaviors and/or if the objectives need to be revised. (Refer to B121)

3. Develop MTPs that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8). Specifically, interventions were stated as generic monitoring and discipline functions written as treatment interventions to be performed by clinical staff. MTPs also failed to consistently state the frequency of contact, specific focus for the intervention, or whether interventions would be delivered in group or individual sessions. In addition, all patients were expected to attend all the groups listed on each unit's schedule. However, the MTPs did not include groups attended by patients from the units' schedules. These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially results in inconsistent and/or ineffective treatment. (Refer to B122)

Interview

In an interview on 6/10/14 at 1:10 p.m., the non-measurable long and short term objectives, which were frequently also staff, not patient oriented and generic interventions on the MTPs were discussed with the Medical Director. He admitted that the reason for this was the existence of the pre-written treatment plans already in the computer program. He stated, "The selections of sample goals and interventions are right there for the staff to select from."

Based on record review and interview, the Director of Nursing failed to monitor to ensure that nursing interventions on the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8) were individualized to meet specific patient needs. Most nursing interventions were generic routine tasks that would be performed regardless of the different patients' problems and needs. This failure results in MTPs that fail to reflect an individualized approach to patient care and fail to guide the nursing staff in providing treatment with a specific focus.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (6/5/14), A6 (6/5/14), B1 (6/5/14), B12 (6/5/14), C6 (6/5/14), C8 (6/5/14), D7 (6/5/14), and D8 (6/4/14) This review revealed that the MTPs had the following routine and generic monitoring, assessing, and evaluating functions written as treatment to be delivered by the registered nurse (RN). Additionally, many treatment plans did not include: 1) how the nursing intervention would be delivered (individual or group sessions); 2) the frequency of contact and/or 3) the focus or purpose of treatment related to the patient's presenting and behaviorally descriptive symptoms.

1. Active sample patient A1 had a problem of "Thought Disorder...The voice is in charge of me." Generic statements were:

"Nursing staff will reinforce medication education when administering medication as scheduled." "Nursing will evaluate medication regime effects and benefits [sic] by monitoring patients behaviors." These statements were not individualized and were routine nursing functions that would be provided any patient regardless of presenting symptoms. This statement did outline specific treatment intervention(s) to assist this patient to accomplish his/her treatment goals.

For the problem of "Potential for self-directed injury...hx of trying to jump off a window," the following nursing interventions did not include a frequency of contact.

"Nursing staff will teach patient behavior self control and coping skills to prevent self injury." "Nursing staff will educate patient on effects of medication and the importance of medication [sic] compliance." These interventions did not include a frequency of contact or whether the interventions would be delivered in group or individual sessions.

2. Active sample patient A6 had the following generic nursing intervention for the problem of "Depression...Manifestations - Suicidal ideation":

"Nursing staff will initiate interactions with patient and encourage verbalization of feelings every shift." This statement was not individualized and did not outline specific treatment interventions(s) to assist this patient to accomplish his/her treatment goals. This statement was actually a generic and routine nursing function written as a treatment intervention and would be provided for any patient regardless of presenting symptoms.

For the problem of "suicide...Manifestations - Suicide risk as evidenced by suicidal thoughts with plan report states pt [patient] said she wanted to drown herself," there were no interventions included for the registered nurse.

3. Active sample patient B1 had the following generic nursing intervention for the problem of "thought disorder...Manifestations - Thought disorder as evidenced by making paranoid statements..."

"Nursing will evaluate medication regime effects and benefits [sic] by monitoring patients [sic] behaviors." This statement was not individualized and did not outline specific treatment interventions(s) such as patient teaching regarding medication that would assist this patient to accomplish his/her treatment goals. This statement was actually a generic and routine nursing function written as a treatment intervention and would be provided for any patient regardless of presenting symptoms.

4. Active sample patient B12 had the following generic nursing interventions for the problem of "Depression...Manifestations - Hopelessness Suicidal ideation Depressed feeling [sic]":

"Nursing staff will encourage attendance in community meetings and groups daily. Nursing staff will initiate interactions with patient and encourage verbalization of feelings every shift." These statements were generic and routine nursing functions that would be provided for any patient regardless of the patient's presenting symptoms.

For the problem of "suicide...Manifestations - Suicide risk as evidenced by suicidal attempt. Suicide risk as evidence by suicidal thoughts with plan OVERDOSE ON PILLS. Suicide risk as evidence by command hallucinations to hurt self," the generic statements written as treatment interventions were:

"Nursing staff will prompt patient to complete activities of daily living while hospitalized." "Nursing will maintain patient on appropriate precaution level (specify) [sic] to provide a safe environment." These interventions written as treatment interventions were generic routine nursing functions that would be provided for any patient regardless of the patient's presenting symptoms.

For the problem of "Medication Noncompliance...Manifestations - PT [Patient] reports not taking medications as prescribed," the treatment intervention was:

"Nursing will encourage pt [patient] to attend Medication Group 3x per week. Nursing will evaluate compliance every shift." Encouraging group attendance and evaluating compliance were routine nursing functions. This intervention did not include a focus for the medication group such as assisting the patient to understand the benefits of continuing to take medications once discharged.

5. Active sample patient C6 had the following generic nursing interventions for the problem of "Thought Disorder...Manifestations - Thought disorder as evidenced by odd or bizarre behavior."

"Nursing staff will teach TIC [sic] behavioral self control and coping skills to prevent outburst and improve impulse control." This intervention did not include a frequency of contact or whether it would be delivered in group or individual sessions. "Unit staff will orient patients [sic] to unit expectations, reinforce expectations throughout hospital stay to provide a calming unit." This was a routine nursing task that would be provided regardless of the patient's presenting symptoms.

6. Active sample patient C8 had no nursing intervention for the problem of "Aggressive/Violence...Manifestations - Striking a Peer in Group Home Residence":

7. Active sample patient D7 had the following generic nursing interventions for the problem of "Substance Abuse...Manifestations - Excessive use of alcohol and marijuana impairing functioning in daily life."

"Nursing staff will provide 1:1 discussions daily on recovery goals." This intervention did not include the specific focus of the interventions that was related to the patient's presenting symptoms and level of functioning. "Nursing staff will utilize withdrawal assessment tools (COWS [Clinical Opiate Scale], CIWAS [Clinical Institute Withdrawal of Alcohol Scale] to assess the patient level of withdrawal [sic] from opioids and alcohol." The use of clinical assessment scales by nurses were generic and routine nursing task function than an individualized intervention related to this patient's level of functioning associated with alcohol abuse as identified in the "Multidisciplinary Assessment Summary."

For the problem of "Depression...Manifestations - Depressed feeling," the generic nursing interventions were:

"Nursing will educate patient on expected therapeutic effects of medication, know side effects, and importance of compliance with medication regime." This intervention did not include a frequency of contact, a delivery method (group or individual sessions), and was not individualized to include specific anti-depressive medication(s) to be taught and compliance issues such as stopped taking medication because of side effects, not able to obtain medications due to financial and/or transportation problems, etc. "Nursing will reinforce medication education while administering medications scheduled." This intervention was a generic and routine nursing function that would be performed for any patient receiving medications.

8. Active sample patient D8 had the following generic nursing intervention for the problem of "Substance Abuse...Manifestations - BAL 324 [sic]"

"Nursing staff will encourage patient to attend substance abuse groups daily." This was a generic and routine nursing function rather than an individualized intervention related to this patient's level of functioning associated with alcohol abuse as identified in the "Multidisciplinary Assessment Summary."

B. Interviews

1. In an interview on 6/10/14 at 7:30 a.m., the generic interventions on the MTPs were discussed with the Director of Nursing (DON). She acknowledged that the interventions were generic and routine interventions on the MTPs. The DON admitted that there was no monitoring data available to determine the effectiveness of nursing practice related to treatment plans or written information available to provide corrective feedback to nursing staff.

2. In an interview on 6/11/14 at 10:00 a.m. with RN #2, MTPs for Patients C6, C8, D7, and D8 were discussed. RN #2 acknowledged that generic and nursing interventions were on the treatment plans. RN #2 admitted the "daily" frequency of contact identified on the MTPs for nursing interventions did not correlate to what was actually done by nursing staff. RN #2 also stated that the Medication Group conducted by registered nurses was not included on the MTP despite the expectation that all patients receiving medication were to attend this group.





07814

Based on record review and interview, the Nursing Director failed to ensure that nursing interventions on the Master Treatment plans for six (6) of eight (8) active sample patients (A5, A7, A10, B4, C1, and C6) were individualized to meet specific patient needs. Most nursing interventions were generic routine tasks that would be performed regardless of the different patients ' problems and needs. This failure results in Master Treatment Plans that fail to reflect an individualized approach to patient care and fail to guide the nursing staff in providing treatment with a specific focus.

Findings include:

A. Record Review

1. Active sample patient A5, Master Treatment Plans (MTP), updated 2/20/14, had a problem of "suicide." Nursing staff interventions:

"Nursing staff will maintain patient on appropriate level, i.e. 15 min [minutes] suicide checks, 1:1 observations, day hall observations to provide a safe environment and decrease suicide attempts."

For the problem of "Depression," the generic nursing staff intervention was as follows:

"Nursing staff will encourage attendance in community meetings, and groups daily." The intervention lacked frequency and focus.


2. Active sample patient A7, MTP dated 2/22/14, had the following generic nursing intervention for the problem of "aggression, violence":

"Nursing staff will provide individual medication education every day." This intervention lacked specific focus of treatment and delivery method.

- For the problem of "Depression," the generic nursing interventions were:

"Nursing will encourage and supervise ADLs [activities of daily living] daily. Nursing staff will provide individual medication education to review benefits and side effects of medications."

- For the problem of "suicide," the generic nursing intervention was:

"Nursing staff will maintain an appropriate precaution level; i.e. 15 minutes suicide checks."


3. Active sample patient A10, MTP dated 2/20/14, had the following generic nursing intervention for the problem of "mania," the generic nursing intervention was:

"Nursing staff will educate on rational benefits and side effects of medications."


4. Active sample patient B4, MTP dated 2/21/14, had the following generic nursing intervention for the problem of "suicide":

"Nursing staff will encourage patient to verbalize feelings and thoughts and alternatives about suicide." No frequency listed.


5. Active sample patient C1, MTP dated 2/20/14, had the following generic nursing intervention for the problem of "substance abuse":

"Nursing staff to provide recovery goals."


6. Active sample patient C6, MTP dated 2/18/14, had the following generic nursing interventions for the problem of "depression":

"Nursing staff will encourage attendance and supervise ADLs daily. Nursing staff will encourage attendance in community meetings and groups daily. Nursing will initiate interactions with patient and encourage verbalization of feeling every shift."

B. Interview

In an interview on 2/25/14 at 1:30 p.m., the generic interventions on the Master Treatment plans were discussed with the Nursing Director. She acknowledged that the interventions were generic but felt that they would get more specific as the treatment team refined each individual patient's needs.

Based on record review and interview, the facility failed to ensure that adequate activity therapy assessments were implemented for eight (8) of eight (8) active sample patients (A1, A6, B1, B12, C6, C8, D7, and D8). The Plan of Correction (POC) for the survey ending 2/27/14 stated, "The Activity Therapist will be vital in the creation of an individualized Activity Assessment completed on all patients." The designated Activity Therapy Assessment was actually a "Group Treatment Update" note written on or close to a patient's admission date to the facility. This note primarily described the patient's behavior on the unit and/or response to any groups attended prior to the documentation. The note also listed selected "short term" and "long-term." The word "goal" was missing. The note failed to include any information on how and why the goals had been selected. The lack of this information hampers the activity staff's ability to provide specific individualized focused care for each patient in a group.

Findings include:

A. Record Review

None of the following active sample patient's "Group Treatment Update" notes (dates of documentation in parenthesis) included adequate information on each patient's needs, interest and possible barriers to an activity in order to formalize an individualized therapeutic activity therapy plan: A1 (6/12/14), A6 (6/2/14), B1 (6/5/14), B12 (6/9/14), C6 (6/5/14), C8 (note missing), D7 (6/5/14) and D8 (6/12/14).


B. Interview

In an interview on 6/11/14 at 1:30 p.m., the lack of adequate patient information on the designated Activity Therapy Assessments was discussed with OT (occupational therapist) #1 who was responsible for completing the assessments for all new admissions. She acknowledged that the "Group Treatment Updates" documentation was considered the Activity Assessment, but admitted that information such as a patient's needs, skills, interest and physical/emotional used to determine an activity schedule for each patient barriers were not included. When asked how she decided on determining long/short-term goals for each patient, she stated that she got this information during the interview, but did not include it in the note.