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Based on record review and staff interview it was determined that the Psychiatric Evaluations for four (4) of eight (8) patients (Patients 5, 6, 7 and 8) failed to include a description of patient assets in descriptive, not interpretive fashion. This failure resulted in no information being made available to the other members of the multidisciplinary treatment team about patient interests, accomplishments etc. that might serve as a guide in the selection of treatment modalities.

Findings include:

I. Record Review:

1. Patient 5: The Psychiatric Evaluation dated 9/20/19 had no assessment of patient assets.

2. Patient 6: The Psychiatric Evaluation dated 8/22/19 stated as the patient strengths, "Housing stability, ability to vocalize needs."

3. Patient 7: The Psychiatric Evaluation dated 8/31/19 stated as the patient strengths, "Housing stability. Ability to vocalize needs."

4. Patient 8: The Psychiatric Evaluation dated 9/18/19 stated as the patient strengths, "Housing stability, ability to vocalize needs."

II. Staff Interview:

On 9/24/19 at 2:15 p.m. the facility's Clinical Director was interviewed. A partial focus of the interview was a discussion of the findings described in Section I, above. The Clinical Director agreed that these were not patient-specific assets.

Based on record review and staff interview it was determined that for four (4) of eight (8) patients (Patients 4, 5, 6 and 8) the Master Treatment Plans failed to be written as observable, measurable patient behaviors to be achieved. Rather the goals were "learn coping skills" and not what the staff observing the patient would consider as an observable, measurable behavioral attainment of whatever "coping skills" had been learned by the patient through selected interventions.

The findings include:

I. Record Review:

1. Patient 4: The Master Treatment Plan dated 9/19/19 stated for the short-term goal "[Patient 4] will...verbalize 2 coping strategies for dealing with...."

2. Patient 5: The Master Treatment Plan dated 9/19/19 stated for the short-term goal "[Patient 5] will...create 3 goals/ 3 coping skills...."

3. Patient 6: The Master Treatment Plan dated 8/21/19 stated for the short-term goal "[Patient 6] will identify 3 coping skills for...."

4. Patient 8: The Master Treatment Plan dated 9/17/19 stated for the short-term goal "[Patient 8] will acquire & rehearse 5 or more coping skills...."

II. Staff Interview:

1.On 9/24/19 at 11:40 a.m. the Assistant Director of Nursing was interviewed. She concurred that the attainment of coping skills was an important component in treatment; however, what observable, measurable patient behaviors the staff could assess to determine progress or lack thereof were not described.

2. On 9/24/19 at 2:15 p.m. the Clinical Director and the Compliance Officer were interviewed. They both agreed that the descriptions for short term goals were not behavioral, measurable behavior goals to be achieved by the patient.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) for six (6) of eight (8) active sample patients (3, 4, 5, 6, 7 and 8) that included individualized nursing and physician treatment interventions with a specific purpose and focus. Most of these interventions on the treatment plans were generic discipline functions/tasks and not based on the patients' specific needs. Failure to clearly describe specific modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs.

Findings include:

A. Record Review

1. Patient 3:

On the Master Treatment Plan [MTP], dated 9/16/19, for the problem "Depressed mood without psychosis as manifested by [first name of patient] asked his/her F [father] to get [him/her] help because [s/he] has been using meth for 3 months, by [his/her] report. [S/he] stated [s/he] was suicidal and [s/he] does have a hx [history] of cutting [him/herself] and an overdose in the past. [S/he] wants to stop using meth for [his/her] own sake and because of [his/her] son."

The generic physician intervention was: "Physician/prn will meet ? [with] [first name of patient] 3x's [three times] a week to discuss treatment goals et [and] medication management."

The nursing intervention was: "Nursing will meet [first name of patient] as needed to educate on [his/her] new medications et [and] encourage treatment participation."

2. Patient 4:

On MTP, dated 9/18/19, for the problem of "Depressed mood without psychosis as manifested by / as evidenced by: Pt. has been losing interest in [his/her] usual activities, not sleeping and eating too much. [S/he] has self-harm ? [with] scissors and by scratching. Others reported [s/he] made suicidal statements. Pt. took a 5-year-old step grand niece off the school bus and was unable to make [his/her] therapy appointment. [First name of patient] has been having difficulty adjusting to living ? F [father] since [he/she] moved to [his/her] home in April."

The generic physician intervention was: "Physician/practitioner will evaluate pt & [and] need for initiation of medication mgmt. [management]. Meet ? pt 2-3 x / wk [two - three times per week] to monitor & [and] evaluate pt. participation in therapies & progress towards goals outlined in POC [plan of care]."

The generic nursing intervention was: "Nursing will administer medications as prescribed appro [appropriate] education: dose & [and] potential SE [side effects]. Encourage pt to participate in all offered groups & therapies."

3. Patient 5:

MTP, dated 9/19/19, for the problem of "Depressed mood without psychosis as manifested by / as evidenced by [name of patient] will report family conflicts, stressors related to sexual identity, peer stressors, family stressors in ? [increase] anxiety, ? depression, ? depressive bx [behaviors]."

The generic part of the physician intervention was: "Will order medication as needed, order labs as needed."

The generic nursing intervention was: "Nursing will dispense meds as ordered, and labs as indicated."

4. Patient 6:

MTP, dated 8/21/19, for the problem "ODD [opposition defiant disorder] as manifested by / as evidenced by: 'I don't follow the rules, get aggression [sic]. Self-harm by stabbing self, get in fights, unstable mood, inability to maintain in programs, police called in response to actions."

The generic physician intervention was: "Prescribe medication and order labs as needed."

The generic part nursing intervention was: "Nsg will dispense meds as ordered."

5. Patient 7:

MTP, dated 8/31/19, for the problem of "Anger aggression as manifested by / as evidenced by: [First name of patient] was admitted into LRH [name of facility] due to misbehavior in school. Pt threw property at other students and was defiant toward teachers."

The generic part of physician intervention was: "Will evaluate [his/her] current medications and adjust as needed."

6. Patient 8:

MTP, dated 9/17/19, for the problem of "Depressed mood without psychosis as manifested by / as evidenced by: [First name of patient] reports having frequent thoughts about killing [his/herself], as well as different ways to achieve in such as stabbing [his/herself] or dropping bricks on [his/herself] head."

The generic physician intervention was: "Manage [name of patient] medication."

The generic nursing intervention was: "Administer [name of patient] medications. Educate [name of patient] about [his/her] medications."

B. Policy Review

The facility's policy on treatment plans, titled "Treatment of Patient 4.5.3 Multidisciplinary Treatment," issued: 01/90, reviewed 09/16; 05.22.2018 states "The written treatment plan is the communication tool which addresses treatment needs including offense specific behaviors; defined the therapeutic focus and purpose of behavior specific interventions and goals."


C. Interviews:

1. In an interview with RN2 on 9/24/19 at 8:53 a.m., the generic nursing interventions on the MTPs were discussed. She agreed with the findings.

2. In an interview with the Nursing Director on 9/24/19 at 12:38 p.m., the generic nursing interventions were discussed. He stated, "I understand what you are saying, but the last CMS surveyors said we should include the administration in the intervention."

3. In an interview with the Medical Director on 9/24/19 at 2:15p.m., the generic physician interventions were discussed. He agreed with the findings.

Based on record review and staff interview it was determined that the clinical director failed to ensure:

1. Psychiatric Evaluations for four (4) of eight (8) patients (Patients 5, 6, 7 and 8) failed to include a description of patient assets in descriptive not interpretive fashion. For details, see B117

2. Master Treatment Plans for four (4) of eight (8) (Patients 4, 5, 6 and 8) failed to describe observable, measurable goals. For details, see B121

3. Master Treatment Plans for six (6) of eight (8) patients (Patients 3, 4, 5, 6, 7 and 8) failed to ensure interventions by physician and nursing staff were more than generic discipline functions. For details, see B122

II. Staff Interview:

On 9/24/19 at 2:15 p.m. the Clinical Director was interviewed. The issues as described in Section I, above, were discussed. He agreed with the findings.

Based on record review and interview, the Director of Nursing failed to ensure that the nursing staff developed MTPs for six (6) of eight (8) active sample patients (3, 4, 5, 6, 7 and 8) that included individualized nursing interventions with a specific focus and purpose and based on the patients' specific needs. Refer to B122 for details