HospitalInspections.org

Based on medical record review, document review, patient interview, and staff interview this facility failed to identify psychiatric diagnoses for 6 of 8 active sample patients (G1, G2, G3, G4, R2, R4), and for two of the 5 sample discharged patients (D3, D4) as well. The facility failed to develop and document comprehensive, psychiatrically focused multidisciplinary treatment plans formulated for individualized psychiatric needs for 7 of 8 active sample patients (G1, G2, G3, G4, R2, R3, R4). Document review of hospital discharges during the month of March, 2013, (dated April 10, 2013) revealed 52% of the patients discharged (total discharges 115 patients) had only a substance abuse diagnosis documented. This facility therefore failed to provide psychiatric services based on a substantiated psychiatric diagnosis as a primary treatment focus for 7 of 8 active patients (G1, G2, G3, G4, R2, R3, R4) sampled. (Refer to B99)

Based on patient record review, document review, and interview this facility failed to:

1. Define psychiatric findings and psychiatric treatment planning for 6 of 8 active sample patients (G1,G2,G3,G4,R2,R4). This failure has the potential to result in a lack of ongoing psychiatric involvement and planning for these patients. (Refer to B104)

2. To develop and document comprehensive, psychiatrically focused multidisciplinary treatment plans formulated from individual needs for 8 of 8 active sample patients (G1,G2,G3,G4, R1, R2, R3, R4). Instead, patients' treatment plans were completed by each discipline in isolation; no actual treatment team meeting occured for patients on the ACU (Adult Care Unit); and the treatment interventions developed for the patients were generic and not individualized. (Refer to B118)

3. To provide a substantiated psychiatric diagnosis on the patients' master treatment plans for 6 of 8 active sample patients (G1,G2,G3,G4,R2,R4) This deficiency can result in the development of a master treatment plan which does not provide necessary information essential to the psychiatric issues for which a patient requires treatment. (Refer to B120)

4. To provide the development of Master Treatment Plans that identified physician, nursing, social work and recreational therapy interventions that were individualized and specific to the treatment needs for 6 of 8 active sample patients (G2, G4, R1, R2, R3, R4). The Master Treatment Plans included written interventions which were routine, generic functions that lacked focus for treatment. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

5. To provide active psychiatric treatment for 7 of 8 active sample patients (G1,G2,G3,G4,R2,R3,R4)) and 2 of 5 discharged patients (D3 and D4). The patients received primarily substance abuse treatment during their stay in the facility. The psychiatric interventions that were offered to patients were routine in nature and involved prescription functions by the physician and initial assessment functions by nursing, counseling, and recreational therapy staff. No other interventions were specifically designed for the treatment of any psychiatric condition. Patient Master Treatment Plans listed Issues (Problems), Goals, Objectives noted primarily a focus on substance abuse treatment. This failed identification of psychiatric issues has resulted in the lack of clear provision of psychiatric care being delivered to patients in a psychiatric hospital. (Refer to B125)

Based on medical record review, document review, and interview, the facility failed to provide psychiatric services as the primary treatment focus for 7 of 8 active sample patients (G1, G2, G3, G4, R2, R3, R4) and 2 of the 5 sample discharged patients (D3 and D4). Patient Master Treatment Plans listed Issues (Problems), Goals, Objectives and interventions with a primary focus on substance abuse treatment. This failure of identification of psychiatric issues resulted in the lack of clear provision of psychiatric care being delivered to patients in a psychiatric hospital.

Findings include:

Active Sample Patient Record Review and patient interviews:

1. Patient G1 admitted 4/1/13 had a psychiatric assessment dated 4/3/13 which listed Axis 1 diagnoses of "Alcohol dependence, Alcohol withdrawal, Opiate dependence, Cannabis abuse, Nicotine dependence." His/her Master Treatment Plan (undated) noted the following Issues, Goals, and Objectives:
Issue 1: "Chronic relapse as evidence by: by repetitive return to chemical use despite serious negative consequences and numerous attempts to quit even after formal support."
Goal: "Capacity to understand and attempt to repair the defects which fuels the relapse."
Objective: "Patient will: Review prior patterns of sobriety and relapse, learning insight into how to change while visiting psychiatrist in weekly sessions."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions"
In an interview on 4/8/13 at 2:30 PM s/he stated s/he had come to the hospital to get help with his/her addictions. S/he was also looking for assistance with housing since s/he had no money and had been homeless for several years.

2. Patient G2 admitted 3/28/13 had a psychiatric assessment dated 3/30/13 which listed an Axis I diagnosis of "Alcohol dependence." His/her Master Treatment Plan dated 4/2/13 noted the following Issues, Goals, and Objectives;
Issue 1: "Need New Priorities in Life as evidenced by continually making poor decisions when faced with options based on need for immediate gratifications and ignoring the needs for others"
Goal: "Capacity to make better decisions, taking into the account the needs of others"
Objective: "Patient will: review post [sic] decisions and new options realizing future priorities based on others' needs and the need to remain sober."
Intervention: "Recognize and point out patient's past behaviors and future options to change course in life in order to maintain sobriety."
Issue 2: "Relapse Prevention as evidenced by relapsing after 8 months of sobriety and seeing a private therapist for [his/her] alcohol dependence"
Goal: "To complete a relapse preventions plan prior to discharge."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."
In an interview on 4/8/13 at 2:00 PM the patient noted drinking up to 1/5 of hard liquor a day and came to the hospital for assistance with detoxification and substance use. The patient noted his/her current medications were only propanolol (a heart medicine), xantac (an antacid), and hydrochlorothiazide (a blood pressure medication).

3. Patient G3 admitted 4/5/13 had a psychiatric assessment dated 4/8/13 which listed Axis 1 diagnoses of "Alcohol dependence, Opiate dependence, Crystal meth dependence, Nicotine dependence, Benzodiazepine abuse, History of cocaine abuse." His/her Master Treatment Plan dated 4/9/13 noted the following Issues, Goals, and Objectives:
Issue: "Chronic relapse as evidence [sic] by: repetitive return to chemical use despite serious negative consequences and numerous attempts to quit even after formal support."
Goal: "Capacity to understand and attempt to repair the deficits which fuels relapse."
Objective: "Patient will: Review prior patterns of sobriety and relapse, learning insight into how to change while visiting psychiatrist in weekly sessions."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."
In an interview on 4/8/13 at 2:45 PM the patient noted s/he had come to the hospital from jail, having detoxed there. S/he came for treatment for his/her addictions, however had been told by his/her lawyer getting treatment would be beneficial to him/her when s/he had to go to court for multiple charges.

4. Patient G4 admitted 3/7/13 had a psychiatric assessment dated 3/8/13 which listed Axis I diagnoses of "Cocaine Dependence, In Early Full Remission, Cannabis Abuse, Nicotine Dependence." (Content of this psychiatric evaluation states " [He/hhad been in jail since yesterday 03/07/13 [sic]...." "[He/she] would smoke five blunts [sic] a day and [his/her] last use was 03/30/12 (the patient was in jail for almost a year prior to admission)." His/her Master Treatment Plan dated 3/14/13 noted the following Issues, Goals, and Objectives:
Issue: "Chronic relapse as evidence [sic] by: by repetitive return to chemical use despite serious negative consequences and numerous attempts to quit even after formal support."
Goal: "Capacity to understand and attempt to repair the deficits which fuels relapse."
Objective: "Patient will: Review prior patterns of sobriety and relapse, learning insight into how to change while visiting psychiatrist in weekly sessions."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."
In an interview on 4/8/13 at 3:30 PM he/she indicated coming to the hospital from jail after being charged with attempted murder. He/she stated being on no meds except iron pills.

5. Patient R2 (MTP dated 4/2/13)
For Issue 1: "Detoxification/Crisis Stabilization Issues," as evidence [sic] by: "Need for safely medically supported detoxification as evidenced by prolonged and heavy use of an opiate/opioid with abrupt discontinuation."
Objective: "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Interventions: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from alcohol or a sedative/hypnotic."
Interventions: "Meet 1:1 weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing [his/her] addiction. Suggest to patient to think of positive ways to manage addiction. Provide information on addiction as needed/requested. Encourage patient to ventilate/acknowledge any frustrations/concerns about [his/her] addiction."
Unnumbered Issue: "Relapse Prevention," as evidenced by: "Patient voices desire/need to learn more about how to prevent relapse."
Objective: "Patient will identify 2 things [s/he] can personally do to prevent relapse,
at least once prior to scheduled date of discharge."
Interventions: "Meet 1:1 weekly to discuss things [he/she] can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following [his/her] continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage [him/her] to be proactive in maintaining [his/her] sobriety and to begin using [his/her] relapse prevention plan while in treatment and after discharge."
In an interview with the patient on 4/8/13 at 11am, the patient's focus of treatment was to get on methadone. In an observation of shift report on 4/8/13 at 2:45 pm, it was stated by staff that patient was hospitalized for methadone treatment with no psychiatric history.

6. Patient R3 (MTP dated 4/3/13)
Issue 1: "Detoxification/Crisis Stabilization Issues, as evidence [sic] by: need for safely medically supported detoxification as evidenced by prolonged and heavy use of alcohol or a sedative/hypnotic with abrupt discontinuation."
Objective: "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Interventions: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from alcohol or a sedative/hypnotic."
Issue 1 [sic]: "Addiction Education," as evidenced by "Patient voices desire/need to learn more about addiction."
Objective: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge."
Interventions: "Meet 1:1 weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing his/her addiction. Provide information on addiction as requested. Encourage patient to ventilate frustrations/concerns about [his/her] addiction."
Unnumbered Issue: "Relapse Prevention," as evidenced by "Patient voices desire/need to learn more about how to prevent relapse."
Objective: "Patient will identify 2 things [he/she] can personally do to prevent relapse at least once prior to scheduled date of discharge."
Interventions: "Meet 1:1 weekly to discuss things [he/she] can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following [his/her] continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage [him/her] to be proactive in maintaining [his/her] sobriety and to begin using [his/her] relapse prevention plan while in treatment and after discharge."
In an interview with the patient on 4/8/13 at 11:30 am, the patient's stated the focus of treatment was to manage his/her drinking problem. In observation of shift report on 4/8/13 at 2:45 pm, staff stated that patient was hospitalized for alcohol treatment with no psychiatric history.

7. Patient R4 (MTP dated 4/4/13)
Issue 1: "Detoxification/Crisis Stabilization Issues, as evidence [sic] by: need for safely medically supported detoxification as evidenced by prolonged and heavy use of cocaine or stimulant with abrupt discontinuation."
Objective: "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Interventions: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from cocaine or stimulant." "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Issue 3: "Stabilization for participation in treatment milieu, as evidence [sic] by: pt's difficulty participating in treatment due to impairment."
Objective: "Patient will increase engagement in the treatment events offered as demonstrated by attendance, participation levels and compliance with all aspects of treatment."
Interventions: "Staff will document attendance to groups, participation in 1:1 sessions and completed assessment process."
In an interview with the patient on 4/8/13 at 12 noon, the patient's focus of treatment was to get "clean before I get too much older." In observation of shift report on 4/8/13 at 2:45 pm, staff stated that patient was hospitalized for methamphetamine abuse and chose hospital treatment rather than jail per judge's directive.

Discharge Record Sample Review

1. Patient D3 admitted 2/28/13 and discharged 3/6/13 had discharge diagnoses of "Opioid Dependence, Nicotine Dependence, Lumbago" listed on the discharge summary. The discharge summary (date not available) noted "History of PTSD, first diagnosed in 2003 after the motor vehicle accident. Patient has never been hospitalized for any psychiatric problems. [S/he] is not currently on any psychiatric medications. [S/he] denies any suicide attempts."

2. Patient D4 admitted on 2/11/13 and discharged 3/6/13 had discharge diagnoses of "Opioid Dependence. Cocaine Abuse, Nicotine Dependence." The discharge summary (date not available) noted "over the course of admission patient gave no endorse of schizophrenia or bipolar disorder. [His/her] mood remained fairly stable throughout with no evidence at any time of mania, depression or psychosis."

Interview:

In an interview on 4/9/13 at 3:30 PM the clinical director confirmed the findings related to patients D3 and D4.

Document Review

1. Hospital document titled "Walter B. Jones, Alcohol and Drug Abuse Treatment Center, Written Plan for Agency Operations Effective 04/08/13" states the following:
"MISSION STATEMENT".... "To provide medically monitored detoxification, crises stabilization, and short-term treatment to prepare adults with substance abuse problems for ongoing community based recovery services."

2. Hospital document "Walter B. Jones ADATC ABSTRACTION APPLICATION, ABS DIAGNOSIS INDEX, Wed Apr 10, 2013" lists the discharge diagnoses for all patients discharged during March, 2013. This document revealed of the 115 discharges for the month of March, 2013, 52% of the patients had a discharge diagnosis of only a substance abuse disorder.

Interviews:

1. In a brief interview on 3/10/13 at the 11:30 AM the CEO indicated that the Mission Statement as listed had typographical errors, and should have included a statement that the facility treated psychiatric problems.

2. In a brief interview on 3/10/13 the Performance Improvement Director validated the document review findings and percentages for the discharge diagnoses for March 2013.

Based on patient record review and interview the hospital did not appropriately identify any psychiatric components, including psychiatric diagnosis or treatment planning for psychiatric issues, for which the patients were hospitalized. This failure resulted in a lack of documentation of need of ongoing psychiatric involvement and planning for these patients.

Findings include:

Record Review

1. Psychiatric assessments for 6 of 8 active sample patients (G1, G2, G3, G4, R2, R4) did not include any psychiatric diagnoses:
Patient G1 admitted 4/1/13 had a psychiatric assessment dated 4/3/13 which listed Axis 1 diagnoses of "Alcohol dependence, Alcohol withdrawal, Opiate dependence, Cannabis abuse, Nicotine dependence."
Patient G2 admitted 3/28/13 had a psychiatric assessment dated 3/30/13 which listed an Axis I diagnosis of "Alcohol dependence."
Patient G3 admitted 4/5/13 had a psychiatric assessment dated 4/8/13 which listed Axis 1 diagnoses of "Alcohol dependence, Opiate dependence, Crystal meth dependence, Nicotine dependence, Benzodiazepine abuse, History of cocaine abuse."
Patient G4 admitted 3/7/13 had a psychiatric assessment dated 3/8/13 which listed Axis I diagnoses of "Cocaine Dependence, In Early Full Remission, Cannabis Abuse, Nicotine Dependence."
Patient R2 admitted 4/2/13 had a psychiatric assessment dated 4/4/13 which listed Axis 1 diagnoses of "Heroin dependence, Nicotine dependence."
Patient R4 admitted 4/4/13 had a psychiatric assessment dated 4/9/13 which listed Axis 1 diagnoses of "Methamphetamine dependence. Marijuana abuse. Nicotine dependence."

2. Treatment plans for 6 of 8 active sample patients (G1, G2, G3, G4, R2, R4) did not document a primary psychiatric diagnosis. The treatment plans were based primarily on primary diagnoses of substance abuse and dependence and not psychiatric illness. (Refer to B120.)

3. Treatment plans for 7 of 8 active sample patients (G1,G2,G3,G4,R2,R3,R4) did not include psychiatric treatment modalities that were related to psychiatric diagnoses. The master treatment plans were based on primary diagnoses of substance dependence, not psychiatric illness and did not include interventions for psychiatric illness. (Refer to B122)

Interview

1. During an interview on 4/9/13 at 2:30 PM. with the Medical Director, the Master Treatment Plan for patients R1, R2, R3 and R4 were reviewed. The Medical Director agreed that the physician interventions on the treatment plans were generic discipline functions unrelated to psychiatric treatment.

2. In an interview on 4/9/13 at 10 am with the Nursing Director, the Master Treatment Plan was reviewed for patients G2, G4, R1, R2, R3 and R4; the Nursing Director agreed that there "cookie-cutter interventions in place" that lacked individualization and were unrelated to psychiatric treatment.

3. In an interview on 4/10/12 at 9 AM Psychiatrist 1 reviewed patient G4's treatment plan with the physician surveyor and LPC (Licensed Professional Counselor) 1. He concurred that the treatment interventions only related to substance abuse treatment. He indicated that "some" patients were admitted for substance abuse treatment only. He acknowledged that treatment staff were able to write addendums to the treatment plan independently and could not confirm that every addendum was approved by the psychiatrist prior to its separate addition to the plan.

Based on interview and medical record review, it was determined that for 5 of 8 sample patients (G1, G3, R1, R3 and R4), the facility failed to complete and have present in the medical records, the psychiatric evaluation within 60 hours of admission. The absence of this information compromises the treatment team's ability to use the psychiatric findings in the development of the master treatment plan.

Findings include:

Medical Records Review

1. Patient G1, admitted on 4/1/13. Psychiatric evaluation was not present on the patient chart upon chart review on 4/8/13. It was not present until 4/9/13.

2. Patient G3, admitted on 4/5/13. Psychiatric evaluation was not present on the patient chart upon chart review 4/8/13. It was not present until late afternoon on 4/9/13.

3. Patient R1, admitted on 4/2/13. Psychiatric evaluation was not present on the patient chart upon chart review 4/8/13. It was not present until 2:40 pm on 4/9/13.

4. Patient R3, admitted on 4/3/13. Psychiatric evaluation was not present on the patient chart upon chart review 4/8/13. It was not present until 2:40 pm on 4/9/13.

5. Patient R4, admitted on 4/4/13. Psychiatric evaluation was not present on the patient chart upon chart review 4/8/13. It was not present until 2:40 pm on 4/9/13.

Policy Review

Walter B. Jones ADATC policy titled "Multi-Disciplinary Approach to Patient Care, revised 6/23/08" states in part, "Time frames for evaluations prior to the treatment team meeting are...psychiatric assessment - 60 hours."

Staff Interview

1. In an interview on 4/8/13 at 4 pm and again on 4/9/13 at 2 pm, LPC1 (Licensed Professional Counselor) validated that the psychiatric evaluations, although they were dictated, were not yet present on the chart.

2. In interview on 4/9/13 at 11 am, the Quality Improvement Director concurred that Patients R1, R3 and R4 did not have psychiatric evaluations present in the medical record.

Based on record review and interview, the facility failed to list patient assets in the Psychiatric Assessments in descriptive terms for 2 of 4 active sample patients on the Adult Crisis Unit (R1, R3). This lack of information hinders the physician's ability to guide the team in developing a plan of care that builds on the patient's assets/strengths.

Findings include:

A. Record Review:

1. Patient R1 was admitted on 4/2/13. The Psychiatric Assessment dated 4/9/13, in the section titled "Assets," noted the following: "not dictated." No other descriptive information was noted.

2. Patient R3 was admitted on 4/3/2013. In a Psychiatric Assessment dated 4/9/13, the section titled "Assets" noted the following: "not dictated." No other descriptive information was noted.

B. Interview

In an interview on 4/9/13 at 2:30 PM, the Medical Director agreed that the assets noted in the above patients' Psychiatric Assessments were not present.

Based on record review, observation and policy review, it was determined that the facility failed to develop and document comprehensive, psychiatrically focused multidisciplinary treatment plans formulated from individual needs for 8 of 8 active sample patients (G1, G2, G3, G4, R1, R2, R3, R4). Instead, patients' treatment plans were completed by each discipline in isolation, no actual treatment team meeting occurred for patients on the ACU (Adult Care Unit), nor were the treatment plans presented to patients on the ACU for their review and signature prior to their discharge from the unit. Record review revealed that preprinted plans contain preprinted "objectives/goals" and "interventions" that were generic (routine clinical responsibilities for the clinical discipline but not patient specific). The absence of an integrated, comprehensive treatment plan resulted in a lack of coordinated and organized treatment with a focus on psychiatric treatment.

Findings include:

Record Review

1. Patient G1 (Master Treatment Plan (MTP) undated
Issue 1: "Chronic relapse as evidence by: by repetitive return to chemical use despite serious negative consequences and numerous attempts to quit even after formal support."
Goal: "Capacity to understand and attempt to repair the defects which fuels the relapse."
Objective: "Patient will: Review prior patterns of sobriety and relapse, learning insight into how to change while visiting psychiatrist in weekly sessions."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."

2. Patient G2 (Master Treatment Plan (MTP) dated 4/2/13)
Issue 1: "Need New Priorities in Life as evidenced by continually making poor decisions when faced with options based on need for immediate gratifications and ignoring the needs for others"
Goal: "Capacity to make better decisions, taking into the account the needs of others"
Objective: "Patient will: review post [sic] decisions and new options realizing future priorities based on others' needs and the need to remain sober."
Intervention: "Recognize and point out patient's past behaviors and future options to change course in life in order to main sobriety."

Issue 2: "Relapse Preventions as evidenced by relapsing after 8 months of sobriety and seeing a private therapist for [his/her] alcohol dependence"
Goal: "To complete a relapse preventions plan prior to discharge"
Objective: "Patient will complete a relapse prevention plan prior to discharge. The patient will identify and verbalize a least 5 ways [he/she] can implement healthy coping skills to daily life learned in groups and individual sessions to prevent relapse."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."

3. Patient G3 (Master Treatment Plan dated 4/8/13)
Issue: "Chronic relapse as evidence [sic] by: by repetitive return to chemical use despite serious negative consequences and numerous attempts to quit even after formal support."
Goal: "Capacity to understand and attempt to repair the deficits which fuels relapse."
Objective: "Patient will: Review prior patterns of sobriety and relapse, learning insight into how to change while visiting psychiatrist in weekly sessions."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."

4. Patient G4 (Master Treatment Plan (MTP) dated 3/13/13)
Issue 1: "Need New Priorities in Life as evidence [sic] by: continually making poor decisions when faced with options based on need for immediate gratifications and ignoring the needs of others."
Objective: "Patient will: review post [sic] decisions taking into the account the needs of others."
Interventions: "Recognize and point out patient's past behaviors and future options to change course in life in order to maintain sobriety."

5. Patient R2 (MTP dated 4/2/13)
Issue 1: "Detoxification/Crisis Stabilization Issues as evidence [sic] by: Need for safely medically supported detoxification as evidenced by prolonged and heavy use of an opiate/opioid with abrupt discontinuation."
Objective: "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Interventions: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from alcohol or a sedative/hypnotic."
Issue 1[sic]: "Addiction Education as evidenced by: Patient voices desire/need to learn more about addiction."
Objective: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge."
Interventions: "Meet 1:1 weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing his/her addiction. Suggest to patient to think of positive ways to manage addiction. Provide information on addiction as needed/requested. Encourage patient to ventilate/acknowledge any frustrations/concerns about his/her addiction."

Unnumbered Issue: "Relapse Prevention, as evidenced by: Patient voices desire/need to learn more about how to prevent relapse."
Objective: "Patient will identify 2 things [he/she] can personally do to prevent relapse,
at least once prior to scheduled date of discharge."
Interventions: Meet 1:1 weekly to discuss things [he/she] can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following [his/her] continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage [him/her] to be proactive in maintaining [his/her] sobriety and to begin using [his/her] relapse prevention plan while in treatment and after discharge."
The Patient Agreement section where the patient was to sign and date and the attending was to initial and date was blank.

6. Patient R3 (MTP dated 4/3/13)
Issue 1: "Detoxification/Crisis Stabilization Issues, as evidence [sic] by: need for safely medically supported detoxification as evidenced by prolonged and heavy use of alcohol or a sedative/hypnotic with abrupt discontinuation."
Objective: "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Interventions: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from alcohol or a sedative/hypnotic."
Issue 1[sic]: "Addiction Education," as evidenced by "Patient voices desire/need to learn more about addiction."
Objective: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge."
Interventions: "Meet 1:1 weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing [his/her] addiction. Provide information on addiction as requested. Encourage patient to ventilate frustrations/concerns about [his/her] addiction."

Unnumbered Issue: "Relapse Prevention," as evidenced by "Patient voices desire/need to learn more about how to prevent relapse."
Objective: "Patient will identify 2 things [he/she] can personally do to prevent relapse at least once prior to scheduled date of discharge."
Interventions: "Meet 1:1 weekly to discuss things [he/she] can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following [his/her] continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage [him/her] to be proactive in maintaining [his/her] sobriety and to begin using [his/her] relapse prevention plan while in treatment and after discharge."
The Patient Agreement section where the patient is to sign and date and the attending is to initial and date is blank.

7. Patient R4 (MTP dated 4/4/13)
Issue 1: "Detoxification/Crisis Stabilization Issues, as evidence [sic] by: need for safely medically supported detoxification as evidenced by prolonged and heavy use of cocaine or stimulant with abrupt discontinuation."
Objective: "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Interventions: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from cocaine or stimulant." "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Issue 3: "Stabilization for participation in treatment milieu, as evidence [sic] by: pt's difficulty participating in treatment due to impairment."
Objective: "Patient will increase engagement in the treatment events offered as demonstrated by attendance, participation levels and compliance with all aspects of treatment."
Interventions: "Staff will document attendance to groups, participation in 1:1 sessions and completed assessment process."
The Patient Agreement section where the patient is to sign and date and the attending is to initial and date is blank.

Policy Review

1. The Patient Treatment Plan policy, revised 2/1/11, states that "each member of the comprehensive treatment team will meet with the patient as assigned. They will ...develop interventions as appropriate to the individual patient's course of treatment."

2. Walter B. Jones' ADATC policy and procedure on Patient Treatment Plans, revised 6/15/08, states on page 3, "The ACU treatment team meeting is held Monday through Friday at 0800."

3. Walter B. Jones' ADATC policy and procedure titled "Multi-Disciplinary Approach to Patient Care", revised 6/23/08, states, "It is the policy of the WBJ/ADATC to have a treatment plan...driven by the patient's individual needs as established during the evaluation and diagnostic process." (p.1)

4. Email 11/9/11 from Program Director to counseling, social work, recreational therapy and discharge planning staff re: ACU treatment plans states,
"I know there are exceptions to this statement, but mostly our folks come to the ACU either too sick to participate in tx for a few days or too resistant to want to participate in tx. When this is the case it should be the identified issue that we are addressing with all other issues to be addressed when this one resolves, if it resolves.
" These are the issues we need to begin placing on tx plans for ACU pts:
When pts are sick and can not participate:
ISSUE: 'Poor participation in treatment due to impairment' (This can be impairment due to intoxication or cognitive/MH issues)
GOAL: 'Increased level of participation in treatment events i.e. assessment process, 1:1 groups and appropriate interaction in the milieu.'

"When pats [sic] are resistant to treatment and choose not to participate
ISSUE: 'Poor participation in treatment due to ambivalence and resistance' (key statements would be 'I don't need to be here,' 'I don't need tx,' 'I am being held against my will," and 'I don't have a problem'
GOAL: 'Increased level of participation in treatment events i.e assessment process, 1:1, groups and appropriate interaction in the milieu' (same as above)
I would like for all of TS [sic] to write their initial objectives under this issue/goal when it is on the tx plan as no discipline can be effective until this issue is resolved....Please do not place multiple issues on the tx plan...2 is fine, 3 is a stretch but definitely no more than 3."

B. Staff Interviews:

1. In an interview on 4/9/13 at 8:30 a.m. with the Therapeutic Recreation Supervisor, the Supervisor stated that staff were advised by email from the Program Standards Manager that on the ACU, global treatment objectives were allowed to be used and gave examples on how these could be written. (See item #4 above.) The Supervisor agreed that the interventions on the Master Treatment Plans for patients R1, R3 and R4 were identical to each other. (The 4th chart, R2, had no treatment plan present for recreational therapy interventions.)

2. In an interview on 4/9/13 at 2:30 pm. with the Medical Director, the Master Treatment Plan for patients R1, R2, R3 and R4 were reviewed. The Medical Director agreed that the interventions on the treatment plans were generic discipline functions.

3. In an interview on 4/9/13 at 10 am with the Nursing Director, the Master Treatment Plan was reviewed for patients G2, G4, R1, R2, R3 and R4; the Director agreed that there were "cookie-cutter interventions in place" that lacked individualization and were not psychiatrically focused. The Nursing Director stated that it was common practice to obtain patient's signatures on MTPs at the time of discharge or transfer to the Rehab Unit.

4. In an interview on 4/9/13 at 3 pm, with the Program Director, the Director acknowledged that what was termed the treatment team meeting for ACU was in reality more correctly termed morning report. The Program Director also acknowledged sending out an email on 11/9/11 to social work, counseling and recreational therapy staff that directed staff to use particular wording in a template format to address "poor participation
in treatment milieu due to impairment," and "poor participation in treatment due to ambivalence and resistance."

5. In an interview on 4/9 at 11 am with the Facility Director, the Director acknowledged that what was termed the treatment team meeting for ACU was more correctly called morning report. He stated that patients did not attend the morning report, and that there were space issues on the ACU, which prevented the ACU treatment team from meeting on the unit.

D. Observation

An observation was made of the "treatment team meeting" 4/9 at 8 am, located on ARS (Adult Rehab Services). Approximately 40 staff were in attendance, a number confirmed by the Quality Improvement Director. The meeting lasted approximately 30 minutes, and all patients were briefly reviewed (approximately 70 patients). No patients were present.

Based on medical record review and interview the facility failed to provide a substantiated psychiatric diagnosis on the patients' master treatment plans for 6 of 8 active sample patients (G1,G2,G3,G4,R2,R4) This deficiency results in the development of a master treatment plan which fails to identify necessary information essential to the documentation that psychiatric issues exist for which a patient requires treatment.

Findings include:

1. Patient G1 admitted on 4/1/13 had a diagnosis of polysubstance abuse/dependence on his/her master treatment plan 4/4/13.

2. Patient G2 admitted on 3/28/13 had a diagnosis of "alcohol depence [sic]" on his/her master treatment plan dated 4/3/13.

3. Patient G3 admitted on 4/5/13 had a diagnosis of polysubstance dependence on his/her master treatment plan dated 4/9/13.

4. Patient G4 admitted on 3/7/13 had a diagnosis of Cocaine Dependence in Early Full Remission, Cannabis Abuse, Nicotine Dependence on his/her master treatment plan dated 3/14/13.

5. Patient R2 admitted on 4/2/13 had a diagnosis of Opioid dependence, Nicotine dependence, Unemployment on his/her master treatment plan (which is not dated)
.
6. Patient R4 admitted on 4/4/13 had a diagnosis of Methamphetamine dependence, Marijuana abuse, Nicotine dependence, chronic pain, unemployment, legal issues on his/her master treatment plan dated 4/6/13.

Interview

1. In an interview on 4/10/13 at 9 AM psychiatrist 1 concurred that the diagnosis listed for patient G4 was a substance abuse only diagnosis.

2. In an interview on 4/9/13 at 2 pm with the Program Director, the Director agreed that he had given guidance (via an email 11/9/11) to the Therapeutic Services staff to concentrate on certain readiness for treatment issues for Acute Care Unit patients upon their admission, and that these foci were substance abuse related.

Based on record review and interview, the facility failed to develop Master Treatment Plans that identified physician, nursing, social work and recreational therapy interventions that were individualized and specific to the treatment needs for 6 of 8 active sample patients (G2, G4, R1, R2, R3, R4). The Master Treatment Plans included written interventions which were routine, generic discipline functions that lacked focus for treatment. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

A review of medical records revealed that the pre-printed treatment plans only listed routine, generic discipline functions as interventions rather than individualized interventions to assist patients to accomplish their treatment goals.

1. Patient G1, admitted 4/1/13 (Master Treatment Plan (MTP) dated 4/3/13)
Issue 1: "Detoxification/Crisis Stabilization Issues" had the following intervention, "(Staff will) Evaluate and prescribe safe and effective medications, interventions, and monitoring as determined by related medical and nursing staff."

2. Patient G2, admitted 3/28/13 (Master Treatment Plan (MTP) dated 4/2/13)
Issue 1: "Need New Priorities in Life," the following Physician intervention was stated: "Recognize and point out patient's past behaviors and future options to change course in life in order to maintain sobriety"

3. Patient G3 admitted 4/5/13 (Master Treatment Plan dated 4/913)
Issue 1: "Chronic relapse as evidence by repetitive return to chemical use despite serious negative consequences and numerous attempts to quite even after formal support", the following physician intervention was stated: "Evaluate relapse patterns and help patient gain insight into behaviors along with other healthy options in weekly sessions."

4. Patient G4 admitted 3/7/13 (Master Treatment Plan (MTP) dated 3/13/13)
Issue 1: "Need New Priorities in Life," the following Physician intervention was stated: "Recognize and point out patient's past behaviors and future options to change course in life in order to maintain sobriety."

5. Patient R1, admitted 4/2/13 (Master Treatment Plan (MTP) dated 4/2/13)
Issue 1: "Detoxification/Crisis Stabilization Issues," the following Physician intervention was stated: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from mixed substances listed above (which is blank)" "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Issue 1 [sic]: "Addiction Education," the following nursing intervention was stated: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge. Meet as needed but at least weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing his/her addiction. Provide information on addiction as requested. Encourage patient to ventilate frustrations/concerns about her addiction."
Issue 3: "Stabilization for participation in treatment milieu," the following nursing intervention was stated: "Patient will increase engagement in treatment by attending 7 out of 10 treatment groups." "Staff will document attendance to groups, participation in 1:1 sessions and completed assessment process."
Issue 4: "TS-RT Services," the following recreational therapy intervention was stated, "Staff will document Pt. attendance and participation level in RT tx group sessions." "Patient will attend and engage in all RT tx group sessions as scheduled."

6. Patient R2, admitted 4/2/13 (MTP dated 4/2/13)
Issue 1: "Detoxification/Crisis Stabilization Issues," the following Physician intervention was stated: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from alcohol or a sedative/hypnotic." "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Issue 1 [sic]: "Addiction Education," the following nursing intervention was stated: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge. Meet as needed but at least weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing his/her addiction. Provide information on addiction as requested. Encourage patient to ventilate frustrations/concerns about her addiction."
Unnumbered Issue: "Relapse Prevention," the following nursing intervention was stated: "Patient will identify 2 things [he/she] can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following [his/her] continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage [him/her] to be proactive in maintaining [his/her] sobriety and to begin using [his/her] relapse prevention plan while in treatment and after discharge."

7. Patient R3 admitted on 4/3/13 (MTP dated 4/3/13)
Issue 1: "Detoxification/Crisis Stabilization Issues," the following Physician intervention was stated: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from alcohol or a sedative/hypnotic." "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Start date, completion date, and staff initials/date are all blank
Issue 1[sic]: "Addiction Education," the following nursing intervention was stated: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge. Meet as needed but at least weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing his/her addiction. Provide information on addiction as requested. Encourage patient to ventilate frustrations/concerns about her addiction."
Unnumbered Issue: "Relapse Prevention," the following nursing intervention was stated: "Patient will identify 2 things he/she can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following his/her continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage him/her to be proactive in maintaining his/her sobriety and to begin using his/her relapse prevention plan while in treatment and after discharge."
The Patient Agreement section where the patient was to sign and date and the attending was to initial and date was blank.

8. Patient R4 admitted on 4/4/13 (MTP dated 4/4/13)
Issue 1: "Detoxification/Crisis Stabilization Issues," the following Physician intervention was stated: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from cocaine or stimulant." "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Issue 3: "Stabilization for participation in treatment milieu," the following nursing intervention was stated: "Patient will increase engagement in the treatment events offered as demonstrated by attendance, participation levels and compliance with all aspects of treatment." "Staff will document attendance to groups, participation in 1:1 sessions and completed assessment process."

B. Staff Interviews

1. In an interview on 4/9/13 at 8:30 a.m. with the Therapeutic Recreation Supervisor, the Supervisor agreed that the interventions on the Master Treatment Plans for patients R1, R3 and R4 were identical to each other.

2. In an interview on 4/9/13 at 2:30 pm. with the Medical Director, the Master Treatment Plan for patients R1, R2, R3 and R4 were reviewed. The Medical Director agreed that the interventions on the treatment plans were generic discipline functions.

3. In an interview on 4/9/13 at 10 am with the Nursing Director, the Master Treatment Plan was reviewed for patients G2, G4, R1, R2, R3 and R4; the Director agreed that there were "cookie-cutter interventions in place" that lacked individualization.

Based on observation, document review, interview and record review, the facility failed to provide active psychiatric treatment for 7 of 8 active sample patients (G1, G2, G3, G4, R2, R3, R4) and 2 of 5 of the sample discharged patients (D3 and D4). The patients received primarily substance abuse treatment during their stay in the facility. The psychiatric interventions that were offered to patients were routine in nature and involved prescription functions by the physician and initial assessment functions by nursing, counseling, and recreational therapy staff. No other interventions were specifically designed for the treatment of a psychiatric condition. Patient Master Treatment Plans listed Issues (Problems), Goals, Objectives noted primarily a focus on substance abuse treatment. This failed identification of psychiatric issues has resulted in the lack of clear provision of psychiatric care being delivered to patients in a psychiatric hospital.

Findings include:

A. Observations

1. On 4/8/13 at 10 am, 5 male patients were observed in a group on the Acute Care Unit. This group consisted of 5 males led by a counselor, with the aim of "talking and getting things off your mind;" R4 stated following the group that the group leader did not focus on any mental health issues with the patients. The intent of the group was to increase insight to the problems substance abuse can cause, in order to assist the patients in avoiding substance use.

2. A "Women's group," held on 04/8/13 at 3 pm on the Acute Care Unit was attended by five female patients, including two active sample patients (R1 and R2). One counselor facilitated the session, and a nurse was also in attendance. The discussion focused on how belief in a higher power or some form of spirituality can help in one's decision to commit to abstinence from substance use. No part of the discussion pertained to psychiatric diagnoses or mental health issues.

3. At 4/10/13 at 9:35 AM an outside recreation therapy group for the ARS (longer term unit) was observed. The activity was called "the chocolate river" and was designed to teach trust among the peers. Patient G1 and patient G2 marginally participated. There were six to eight other patients who also participated. This group was not listed as an intervention for either patient's issues and did not relate to psychiatric issues

B. Document Review

1. Hospital document titled "Walter B. Jones, Alcohol and Drug Abuse Treatment Center, Written Plan for Agency Operations Effective 04/08/13 states the following:
"MISSION STATEMENT".... "To provide medically monitored detoxification, crises stabilization, and short-term treatment to prepare adults with substance abuse problems for ongoing community based recovery services"
2. Hospital document "Walter B. Jones ADATC ABSTRACTION APPLICATION, ABS DIAGNOSIS INDEX, Wed Apr 10, 2013 lists the discharge diagnoses for all patients discharged during March, 2013." This document reveals of the 115 discharges for the month of March, 2013, 52% of the patients had only a discharge diagnosis of a substance abuse disorder.

C. Interview

1. In a brief interview on 3/10/13 at the 11:30 AM the CEO indicated that the Mission Statement as listed had typographical errors, and should have included wording that the facility also treated psychiatric problems.

2. In a brief interview on 3/10/13 the Performance Improvement Director validated the findings and percentages for the discharge diagnoses for March 2013.

D. Active Sample Patient Record Review:

1. Patient G1 admitted 4/1/13 had a psychiatric assessment dated 4/3/13 which listed Axis 1 diagnoses of "Alcohol dependence, Alcohol withdrawal, Opiate dependence, Cannabis abuse, Nicotine dependence." His/her Master Treatment Plan (undated) noted the following Issues, Goals, and Objectives:
Issue 1: "Chronic relapse as evidence by: by repetitive return to chemical use despite serious negative consequences and numerous attempts to quit even after formal support."
Goal: "Capacity to understand and attempt to repair the defects which fuels the relapse."
Objective: "Patient will: Review prior patterns of sobriety and relapse, learning insight into how to change while visiting psychiatrist in weekly sessions."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."
In an interview on 4/8/13 at 2:30 PM he/she indicated s/he had come to the hospital to get help with his/her addictions. He/she had previously been hospitalized at Walter B Jones and had smoked a cigarette so he/she could be "thrown out" and go use again. He/she was also looking for assistance with housing since he/she had no money and had been homeless for several years.

2. Patient G2 admitted 3/28/13 had a psychiatric assessment dated 3/30/13 which listed an Axis I diagnosis of "Alcohol dependence." His/her Master Treatment Plan dated 4/2/13 noted the following Issues, Goals, and Objectives;
Issue 1: "Need New Priorities in Life as evidenced by continually making poor decisions when faced with options based on need for immediate gratifications and ignoring the needs for others"
Goal: "Capacity to make better decisions, taking into the account the needs of others"
Objective: "Patient will: review post [sic past] decisions and new options realizing future priorities based on others' needs and the need to remain sober
Intervention: "Recognize and point out patient's past behaviors and future options to change course in life in order to main sobriety."
Issue 2: "Relapse Preventions as evidenced by relapsing after 8 months of sobriety and seeing a private therapist for his alcohol dependence"
Goal: "To complete a relapse preventions plan prior to discharge."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."
In an interview on 4/8/13 at 2:00 PM the patient noted drinking up to 1/5 of hard liquor a day and came to the hospital for assistance with detoxification and substance use. The patient noted his/her current medications were only propanolol (for heart problems), xantac (an antacid), and hydrochlorothiazide (HCTZ--- for blood pressure)

3. Patient G3 admitted on 4/5/13 had a psychiatric assessment dated 4/8/13 listed Axis 1 diagnoses of "Alcohol dependence, Opiate dependence, Crystal meth dependence, Nicotine dependence, Benzodiazepine abuse, History of cocaine abuse." His/her Master Treatment Plan dated 4/9/13 noted the following Issues, Goals, and Objectives:
Issue: "Chronic relapse as evidence [sic] by: by repetitive return to chemical use despite serious negative consequences and numerous attempts to quit even after formal support."
Goal: "Capacity to understand and attempt to repair the deficits which fuels relapse."
Objective: "Patient will: Review prior patterns of sobriety and relapse, learning insight into how to change while visiting psychiatrist in weekly sessions."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."
In an interview on 4/8/13 at 2:45 PM the patient noted he/she had come to the hospital from jail, having detoxed there. He/she came for treatment for his/her addictions, however had been told by his/her lawyer getting treatment would be beneficial to him/her when he/she had to go to court for multiple charges.

4. Patient G4 admitted on 3/7/13 had a psychiatric assessment dated 3/8/13 listed Axis I diagnoses of "Cocaine Dependence, In Early Full Remission, Cannabis Abuse, Nicotine Dependence." (Content of this psychiatric evaluation states "[He/she] had been in jail since yesterday 03/07/13(sic)...." "[He/she] would smoke five blunts [sic] a day and [his/her] last use was 03/30/12." His/her Master Treatment Plan dated 3/14/13 noted the following Issues, Goals, and Objectives:
Issue: "Chronic relapse as evidence [sic] by: by repetitive return to chemical use despite serious negative consequences and numerous attempts to quit even after formal support."
Goal: "Capacity to understand and attempt to repair the deficits which fuels relapse."
Objective: "Patient will: Review prior patterns of sobriety and relapse, learning insight into how to change while visiting psychiatrist in weekly sessions."
Interventions: "Evaluate relapse patterns and help patient gain insight into behavior along with other healthy options in weekly sessions."
In an interview on 4/8/13 at 3:30 PM he/she indicated coming to the hospital from jail after being charged with attempted murder. He/she stated being on no meds except iron pills.
.
5. Patient R2 (MTP dated 4/2/13)
Issue 1: "Detoxification/Crisis Stabilization Issues, as evidence [sic] by: Need for safely medically supported detoxification as evidenced by prolonged and heavy use of an opiate/opioid with abrupt discontinuation."
Objective: "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Interventions: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from alcohol or a sedative/hypnotic."
Issue 1[sic]: "Addiction Education," as evidenced by: "Patient voices desire/need to learn more about addiction
Objective: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge.
Interventions: "Meet 1:1 weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing his/her addiction. Suggest to patient to think of positive ways to manage addiction. Provide information on addiction as needed/requested. Encourage patient to ventilate/acknowledge any frustrations/concerns about [his/her] addiction. "
Unnumbered Issue: "Relapse Prevention," as evidenced by: "Patient voices desire/need to learn more about how to prevent relapse."
Objective: "Patient will identify 2 things [he/she] can personally do to prevent relapse,
at least once prior to scheduled date of discharge."
Interventions: "Meet 1:1 weekly to discuss things [he/she] can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following [his/her] continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage [him/her] to be proactive in maintaining [his/her] sobriety and to begin using [his/her] relapse prevention plan while in treatment and after discharge."

In an interview on 4/8/13 at 11 am, the patient stated the focus of treatment was to get on methadone. During observation of shift report on 4/8/13 at 2:45 pm, staff stated that patient was hospitalized for methadone treatment with no psychiatric history.

6. Patient R3 (MTP dated 4/3/13)
Issue 1: "Detoxification/Crisis Stabilization Issues, as evidence [sic] by: need for safely medically supported detoxification as evidenced by prolonged and heavy use of alcohol or a sedative/hypnotic with abrupt discontinuation."
Objective: "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Interventions: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from alcohol or a sedative/hypnotic."
Issue 1[sic]: "Addiction Education," as evidenced by "Patient voices desire/need to learn more about addiction."
Objective: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge."
Interventions: "Meet 1:1 weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing [his/her] addiction. Provide information on addiction as requested. Encourage patient to ventilate frustrations/concerns about [his/her] addiction."
Unnumbered Issue: "Relapse Prevention," as evidenced by "Patient voices desire/need to learn more about how to prevent relapse."
Objective: "Patient will identify 2 things [he/she] can personally do to prevent relapse at least once prior to scheduled date of discharge."
Interventions: "Meet 1:1 weekly to discuss things [he/she] can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following [his/her] continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage [him/her] to be proactive in maintaining [his/her] sobriety and to begin using [his/her] relapse prevention plan while in treatment and after discharge."
In an interview with the patient on 4/8/13 at 11:30 am, the patient stated the focus of treatment was to manage his/her drinking problem. In observation of shift report on 4/8/13 at 2:45 pm, staff stated that patient was hospitalized for alcohol treatment with no psychiatric history.

7. Patient R4 (MTP dated 4/4/13)
Issue 1: "Detoxification/Crisis Stabilization Issues, as evidence [sic] by: need for safely medically supported detoxification as evidenced by prolonged and heavy use of cocaine or stimulant with abrupt discontinuation."
Objective: "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Interventions: "Staff will evaluate and prescribe safe and effective medications/interventions to help assure a safe, comfortable, and humane withdrawal from cocaine or stimulant." "Patient will comply with prescribed medications, maneuvers and monitoring as determined by related medical and nursing staff."
Issue 3: "Stabilization for participation in treatment milieu, as evidence [sic] by: pt's difficulty participating in treatment due to impairment."
Objective: "Patient will increase engagement in the treatment events offered as demonstrated by attendance, participation levels and compliance with all aspects of treatment."
Interventions: "Staff will document attendance to groups, participation in 1:1 sessions and completed assessment process."
In an interview with the patient on 4/8/13 at 12 noon, the patient's focus of treatment was stated as to get "clean before I get too much older." In observation of shift report on 4/8/13 at 2:45 pm, staff stated that patient was hospitalized for methamphetamine abuse and chose hospital treatment rather than jail per judge's directive.

Discharge Record Sample Review

1. Patient D3, admitted 2/28/13 and discharged 3/6/13, had discharge diagnoses of "Opioid Dependence, Nicotine Dependence, Lumbago" listed on the discharge summary. The discharge summary (date not available) noted "History of PTSD, first diagnosed in 2003 after the motor vehicle accident. Patient has never been hospitalized for any psychiatric problems. [S/he] is not currently on any psychiatric medications. [S/he] denies any suicide attempts."

2. Patient D4, admitted on 2/11/13 and discharged 3/6/13, had discharge diagnoses of "Opioid Dependence. Cocaine Abuse, Nicotine Dependence." The discharge summary (date not available) noted "over the course of admission patient gave no endorse [sic] of schizophrenia or bipolar disorder. [His/her] mood remained fairly stable throughout with no evidence at any time of mania, depression or psychosis."

In an interview on 4/9/13 at 3:30 PM the clinical director confirmed these findings.

Based on patient record review and interview, the medical director failed to ensure that:

1. Psychiatric assessments for 6 of 8 active sample patients (G1,G2,G3,G4,R2,R4) did not include any psychiatric diagnoses:
Patient G1 admitted 4/1/13 had a psychiatric assessment dated 4/3/13 which listed Axis 1 diagnoses of "Alcohol dependence, Alcohol withdrawal, Opiate dependence, Cannabis abuse, Nicotine dependence."
Patient G2 admitted 3/28/13 had a psychiatric assessment dated 3/30/13 which listed an Axis I diagnosis of "Alcohol dependence."
Patient G3 admitted 4/5/13 had a psychiatric assessment dated 4/8/13 which listed Axis 1 diagnoses of "Alcohol dependence, Opiate dependence, Crystal meth dependence, Nicotine dependence, Benzodiazepine abuse, History of cocaine abuse."
Patient G4 admitted 3/7/13 had a psychiatric assessment dated 3/8/13 which listed Axis I diagnoses of "Cocaine Dependence, In Early Full Remission, Cannabis Abuse, Nicotine Dependence."
Patient R2 admitted 4/2/13 had a psychiatric assessment dated 4/4/13 which listed Axis 1 diagnoses of "Heroin dependence, Nicotine dependence."
Patient R4 admitted 4/4/13 had a psychiatric assessment dated 4/9/13 which listed Axis 1 diagnoses of "Methamphetamine dependence. Marijuana abuse. Nicotine dependence."

2. Medical staff complete and have present in the medical records, the psychiatric evaluation within 60 hours of admission for 5 of 8 sample patients (G1, G3, R1, R3,R4). The absence of this information compromises the treatment team's ability to use the psychiatric findings in the development of the master treatment plan. (Refer to B111)

3. Clinical staff develop and document comprehensive, psychiatrically focused multidisciplinary treatment plans formulated from individual needs for 8 of 8 active sample patients (G1,G2,G3,G4, R1, R2, R3, R4). Instead, patients' treatment plans were completed by each discipline in isolation, and no actual treatment team meeting occurred for patients on the ACU. The treatment interventions developed for the patients were generic and not individualized. (Refer to B118)

4. Medical staff provide a substantiated psychiatric diagnosis on the patients' master treatment plans for 6 of 8 active sample patients (G1, G2, G3, G4, R2, R4) This deficiency can result in the development of a master treatment plan which does not provide necessary information to establish that there are psychiatric issues for which a patient requires treatment. (Refer to B120)

5. Clinical staff assure the development of Master Treatment Plans that identified physician, nursing, social work and recreational therapy interventions that were individualized and specific to the treatment needs for 6 of 8 active sample patients (G2, G4, R1, R2, R3, R4). The Master Treatment Plans included written interventions which were routine, generic discipline functions that lacked focus for treatment. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

6. Clinical staff provide active psychiatric treatment for 7 of 8 active sample patients (G1,G2,G3,G4,R2,R3,R4)) and 2 of the sample discharged patients (D3 and D4). The patients received substance abuse treatment during their stay in the facility. The psychiatric interventions that were offered to patients were routine in nature and involved prescription functions by the physician and initial assessment functions by nursing, counseling,
and recreational therapy staff. No other interventions were specifically designed for the treatment of a psychiatric condition. Patient Master Treatment Plans listed Issues (Problems), Goals, Objectives with a primary focus on substance abuse treatment. This failed identification of psychiatric issues has resulted in the lack of clear provision of psychiatric care being delivered to patients in a psychiatric hospital. (Refer to B125)

Based on record review and interview, the Nursing Director failed to ensure that nursing staff developed interventions on the Master Treatment plans that addressed the individual needs for 6 of 8 active sample patients (G2, G4, R1, R2, R3, R4). The Master Treatment Plans included written interventions which were routine, generic discipline functions that lacked focus for treatment. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. Instead, many interventions were routine, generic discipline functions that would be provided for any patient regardless of specific goals and needs. This deficiency results in treatment plans that do not reflect a comprehensive, integrated individualized approach to patient care.
Findings include:

A. Record Review (MTP dates in parentheses)

1. Hospital policy, titled Clinical Care Plan, p.4, section 17 states in part, "Each member of the comprehensive treatment team will...complete assessments based on their discipline and develop, in conjunction with the patient, issues, goals, objectives and interventions as appropriate to the individual patient's course of treatment.

2. Patient R1 (Master Treatment Plan (MTP) dated 6/3/2011)
For Issue 1: "Addiction Education," the following nursing intervention was stated: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge. Meet as needed but at least weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing his/her addiction. Provide information on addiction as requested. Encourage patient to ventilate frustrations/concerns about her addiction."
For Issue 3: "Stabilization for participation in treatment milieu," the following nursing intervention was stated: "Patient will increase engagement in treatment by attending 7 out of 10 treatment groups." "Staff will document attendance to groups, participation in 1:1 sessions and completed assessment process."

3. Patient R2 (MTP dated 4/2/13)
For Issue 1: "Addiction Education," the following nursing intervention was stated: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge. Meet as needed but at least weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing [his/her] addiction. Provide information on addiction as requested. Encourage patient to ventilate frustrations/concerns about [his/her] addiction."
For an unnumbered Issue: "Relapse Prevention," the following nursing intervention was stated: "Patient will identify 2 things [he/she] can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following [his/her] continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage [him/her] to be proactive in maintaining [his/her] sobriety and to begin using [his/her] relapse prevention plan while in treatment and after discharge."

4. Patient R3 (MTP dated 4/3/13)
For Issue 1: "Addiction Education," the following nursing intervention was stated: "Patient will be able to verbalize (3 - 5) reasons to use all prescribed medications only as prescribed at least twice before scheduled date of discharge. Meet as needed but at least weekly to discuss addiction, use of unprescribed substances/medications, use of prescribed medications only as prescribed/ordered by MD, negative impact of addiction of life, benefits of managing addiction and encourage patient to be proactive in managing his/her addiction. Provide information on addiction as requested. Encourage patient to ventilate frustrations/concerns about [his/her] addiction."
For an unnumbered Issue: "Relapse Prevention," the following nursing intervention was stated: "Patient will identify 2 things [he/she] can personally do to prevent relapse, discuss active ways to prevent relapse, discuss developing an active support network, discuss importance of following [his/her] continuing care plan and encourage completion of a workable relapse plan while in treatment. Encourage [him/her] to be proactive in maintaining [his/her] sobriety and to begin using [his/her] relapse prevention plan while in treatment and after discharge."

5. Patient R4 (MTP dated 4/4/13)
For Issue 3: "Stabilization for participation in treatment milieu," the following nursing intervention was stated: "Patient will increase engagement in the treatment events offered as demonstrated by attendance, participation levels and compliance with all aspects of treatment." "Staff will document attendance to groups, participation in 1:1 sessions and completed assessment process."

B. Interview

In an interview on 4/9/13 at 8:45 a.m., the generic nursing interventions were discussed with the Nursing Director. The Nursing Director agreed that the goals were not individualized. "They are general."