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Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals in observable, measurable, behavioral terms for seven (7) of nine (9) active patients (A1, A2, A3, A4, A5, A6 and A7). The lack of measureable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings Include:

A. Specific Patients Findings

1. Patient A1 was admitted on 01/21/16. The Problems/Needs List for the Master Treatment Plan (MTP) dated 01/28/16, narrated the reasons for admission but did not identify specific problems to be addressed on the MTP. The short term goal numbered 1.1 lacked reference to a specific problem and was stated as, "[Patient] will demonstrate increased awareness of [his/her] mental illness by choosing to adhere to [his/her] prescribed medication to manage symptoms, for 30 consecutive days, by the target date."

2. Patient A2 was admitted on 02/11/16. The Problems/Needs List for the MTP dated 2/18/16, narrated the reasons for admission but did not identify specific problems to be addressed on the MTP. The short term goal numbered 1.1 lacked reference to a specific problem and was stated as, "[Patient] will demonstrate increased awareness of [his/her] mental illness and its related needs by choosing to accept prescribed psychotropic medications for 30 consecutive days."

3. Patient A3 was admitted on 02/05/16. The Problems/Needs List for the MTP dated 02/2/16, narrated the reasons for admission but did not identify specific problems to be addressed on the MTP. The short term goal numbered 1.3 lacked reference to a specific problem and was stated, "[Patient] will demonstrate increased awareness of [his/her] mental illness by choosing to adhere to [his/her] prescribed medication to manage symptoms of paranoia, for 30 consecutive days, by the target date."

4. Patient A4 was admitted on 02/12/16. The Problems/Needs List for the MTP dated 01/18/16, narrated the reasons for admissions but did not identify specific problems to be addressed on the MTP. The short term goal numbered 1.2 lacked reference to a specific problem and was stated, "[Patient] will demonstrate an increased awareness of [his/her] mental illness by choosing to take [his/her] medications as prescribed, naming symptoms of [his/her] illness and ways manage [sic] [his/her] symptoms and remain free of substance abuse when asked by staff, and work with symptoms and remain free of substance abuse when asked by staff, and work with SW (Social Worker) and CSB (Community Service Board) to make plans for follow up services at discharge."

5. Patient A5 was admitted on 02/12/16. The Problems/Needs List for the MTP dated 02/19/16, narrated the reasons for admission but did not identify specific problems to be addressed on the MTP. The short term goal numbered 1.2 lacked reference to a specific problem and was stated as, "[Patient] will demonstrate increased awareness of [his/her] mental illness and its related needs by choosing to accept prescribed psychotropic medications for 30 consecutive days."

6. Patient A6 was admitted on 02/01/16. The Problems/Needs List for the MTP dated 02/08/16, narrated the reasons for admission but did not identify specific problems to be addressed on the MTP. The short term goal numbered 1.1 lacked reference to a specific problem and was stated as, "[Patient] will develop increased awareness of [his/her] diagnoses as evidenced by taking medications as prescribed, describing [his/her] symptoms in treatment team, and identifying two coping mechanisms."

7. Patient A7 was admitted on 02/03/16. The Problems/Needs List for the MTP dated 02/09/16, narrated the reasons for admission but did not identify specific problems to be addressed on the MTP. The short term goal numbered 1.1 lacked reference to a specific problem and was stated as, "[Patient] will demonstrate ongoing awareness of [his/her] mental illness by choosing to adhere to [his/her] prescribed medication, by the target date."

B. Interviews

1. During interview on 02/23/16 at 11:40 AM, the Clinical Director agreed that the short term goals were not measureable.

2. During interview on 02/23/16 at 4:00 PM, RN4 acknowledged that the short term goals were not written in behavioral, measureable terms.