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Based on record review and staff interview, the Psychiatric Evaluations for three (3) of three (3) active sample patients (A2, A3 and A4) lacked a diagnostic formulation based on the findings contained therein. The multiaxial diagnoses were based on Psychiatric Evaluations done months before the current admitting evaluations. This failure results in a complete lack of conclusions based on current presenting symptomatology.

Findings include:

A. Medical Record Review:

1. Patient A2: The Psychiatric Evaluation, dated 9/16/14, had a diagnostic formulation that had occurred 5/1/14. The Axis I primary diagnosis was "Opioid Induced Mood Disorder." The information written in the admitting Psychiatric Evaluation stated "She/he had a hx [history] of opiate dependency, but had been off opiates for a month." There was no other information to support this prior diagnosis.

2. Patient A3: The Psychiatric Evaluation, dated 9/20/14, had a diagnostic formulation that had been established 4/24/14.

3. Patient A4: The Psychiatric Evaluation, dated 9/3/14, had a diagnostic formulation that had been established 5/20/14.


B. Staff Interview:

On 9/23/14 at 11:00 a.m., the Clinical Director and the Director of Nursing met with the surveyors. The 2 staff members agreed that the diagnostic formulations had occurred several months earlier. They agreed that for patient A1 there was no information in the Admitting Evaluation that would support the conclusions stated. They also agreed that the examining psychiatrist did not state that current findings supported the out-of-date formulations.

Based on record review and interview, the facility failed to develop Master Treatment Plans that consistently included active treatment interventions with a specific focus. Interventions were generic monitoring and discipline functions to be performed by physicians, nurses and social work staff. This deficiency results in a document that fails to identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to actually measure individual progress in care.

Findings include:

A. Record Review;

1. Facility policy titled "Treatment Plan", last revised 8/14, states "A Master Treatment Plan will be created on the 3rd day of admission or no longer than 72 hours after admission."---"A comprehensive treatment plan will be developed starting with a review of the initial plan and incorporating issues that were identified from the assessments of the previous day (s). The team decides on what problems will be addressed while on the unit, establish long and short term goals and develop measurable objectives and interventions." Interventions related to a patient's specific problems and needs, as well as inclusions of a specific focus and description of the intervention(s) were not mentioned in the policy.

2. Active sample patient A2 was admitted on 9/16/14. The treatment plan, dated 9/16/14, stated the following generic and routine discipline interventions which did not consistently include a focus for the identified problem of "Gravely disabled, manic":

Physician - "Place on precaution," "Assess the need for medication change" and "Abilify."

Nursing - "Monitor per precautions," "Assess patient ' s thoughts and behaviors" and "Administer medications as ordered."

Social Work - "Individual and group coping skills," "Collateral contacts to coordinate treatment" and "Establish a safety contract." The second intervention did have a focus.

3. Active sample patient A3 was admitted on 9/19/14. The treatment plan, dated 9/19/14, stated the following generic and routine discipline interventions which did not consistently include a focus for the identified problem of "patient reports increased depression":

Physician - "Place on precautions" and "evaluate for the need to start/adjust medications."

Nursing - "Monitor for safety" and "education on medication/disease process."

Social Work - "Individual and group to help improve coping skills," "Collateral contacts to help coordinate discharges," and "complete safety contracts." The first 2 interventions did include a focus.

4. Active sample patient A4was admitted on 9/2/14. The treatment plan, dated 9/2/14, stated the following generic and routine discipline interventions which did not consistently include a focus for the identified problem of "patient reports increased depression":

Physician - "Place on precautions," "evaluate for the need to start/adjust medications" and "Latuda."

Nursing - "Monitor safety," "education on medication/disease process," "administer medication as ordered" and "encourage patient to participate in treatment."

Social Work - "Individual and group to help improve coming skill," "collateral contacts to help coordinate discharge" and "complete safety contract." The first two social work interventions did include a focus.


B. Interviews

1. In an interview on 9/23/14 at 11:45 a.m., the generic interventions on the Master Treatment plans were discussed with the Medical Director. He did not dispute the findings.

2. In an interview on 9/23 at 11:45 a.m., the generic Nursing Interventions on the Master Treatment plan was discussed with the Director of Nursing. She replied, "They [treatment plans] are better, but we will get there (meaning do a better job)."

Based on review and interview, the Medical Director failed to ensure the quality and appropriateness of psychiatric care documented on three (3) of three (3) active sample patients (A2, A3 and A4). Specifically, the Medical Director failed to:

I. Ensure that the Psychiatric Evaluations for (3) of three (3) active sample patients (A2, A3 and A4) contained a diagnostic formulation based on current findings. The multiaxial diagnoses were based on Psychiatric Evaluations done months before the current admitting evaluations. This failure results in a complete lack of conclusions based on current presenting symptomatology. (Refer to B110)

II. Ensure that developed Master Treatment Plans consistently included individualized treatment interventions with a specific focus. Interventions were generic monitoring and discipline functions to be performed by physicians, nurses and social work staff. This deficiency results in a document that fails to identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to actually measure individual progress in care. (Refer to B122)

Based on review and interview, the Director of Nursing failed to ensure the quality and appropriateness of nursing care documented on (3) of three (3) active sample patients (A2, A3 and A4). Specifically, the Director of Nursing failed to ensure that developed Master Treatment Plans consistently included individualized treatment interventions with a specific focus. Interventions were generic monitoring and discipline functions to be performed by nursing staff. This deficiency results in a document that fails to identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to actually measure individual progress in care.

Findings include:

A. Record Review:

1. Facility policy titled "Treatment Plan", last revised 8/14, stated "A Master Treatment Plan will be created on the 3rd day of admission or no longer than 72 hours after admission."---"A comprehensive treatment plan will be developed starting with a review of the initial plan and incorporating issues that were identified from the assessments of the previous day (s).The team decides on what problems will be addressed while on the unit, establish long and short term goals, and develop measurable objectives and interventions." Interventions related to a patient's specific problems and needs, as well as inclusions of a specific focus and description of the intervention(s), were not mentioned in the policy.

2. Active sample patient A2 was admitted on 9/16/14. The treatment plan, dated 9/16/14, stated the following Nursing generic and routine discipline interventions which lacked a focus for the identified problem of "Gravely disabled, manic":

Nursing - "Monitor per precautions", "Assess patient's thoughts and behaviors," "Assess the need for medication" and "Administer medications as ordered."

3. Active sample patient A3 was admitted on 9/19/14. The treatment plan, dated 9/19/14, stated the following Nursing generic and routine discipline interventions which lacked a focus for the identified problem of "patient reports increased depression":

Nursing - "Monitor for safety" and "education on medication/disease process."

4. Active sample patient A4 was admitted on 9/2/14. The treatment plan, dated 9/2/14, stated the following Nursing generic and routine discipline interventions which lacked a focus for the identified problem of "patient reports increased depression":

Nursing - "Monitor safety," "education on medication/disease process," "administer medication as ordered" and "encourage patient to participate in treatment."

B. Interview

In an interview on 9/23 at 11:45 a.m., the generic Nursing Interventions on the Master Treatment plans were discussed with the Director of Nursing. She replied, "They [treatment plans] are better, but we will get there (meaning do a better job)."

Based on record review and interview, the Director of Social Work failed to ensure the quality and appropriateness of psychiatric care documented by Social work staff for (3) of three (3) active sample patients (A2, A3 and A4). Specifically, the Director of Social Work failed to ensure that Master Treatment Plans consistently included active treatment interventions with a specific focus by Social Work staff. Interventions were primarily generic monitoring and discipline functions to be performed by social work staff. This deficiency results in a document that fails to identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to actually measure individual progress in care.

Findings include:

A. Record Review:

1. Facility policy titled "Treatment Plan", last revised 8/14, stated "A Master Treatment Plan will be created on the 3rd day of admission or no longer than 72 hours after admission."---" A comprehensive treatment plan will be developed starting with a review of the initial plan and incorporating issues that were identified from the assessments of the previous day (s). The team decides on what problems will be addressed while on the unit, establish long and short term goals, and develop measurable objectives and interventions." Interventions related to a patient's specific problems and needs, as well as inclusions of a specific focus and description of the intervention(s) were not mentioned in the policy.

2. Active sample patient A3 was admitted on 9/19/14. The treatment plan, dated 9/19/14, stated the following generic and routine Social Work discipline interventions which did not consistently include a focus for the identified problem of "patient reports increased depression":

Social Work - "Individual and group to help improve coping skills," "Collateral contacts to help coordinate discharges," and "complete safety contracts." The first 2 interventions did contain a focus, but were generic in nature. The last generic intervention did not contain a focus.

3. Active sample patient A4was admitted on 9/2/14. The treatment plan, dated 9/2/14, stated the following generic and routine Social Work discipline interventions which did not consistently provide a focus for the identified problem of "patient reports increased depression":

Social Work - "Individual and group to help improve coming skill," "collateral contacts to help coordinate discharge," "complete safety contract." The first two generic social work interventions did include a focus. The last one did not.


B. Interview

In an interview on 9/23/14 at 2:10 p.m., the generic social work interventions were discussed with the Director of Social Work (also known as the Acting Director of Clinical Services). She did not dispute the findings.