“Oh, no! The surveyors cited us again for treatment planning.” It’s an all-too-common refrain following a Joint Commission or CMS survey. Sure, it’s frustrating and, yes, there is surveyor variability. But if you tackle the  the most common pitfalls, you’ll definitely minimize the damage.

Treatment Planning in the Top 5

Treatment planning issues continue to be in the Top 5 Joint Commission survey findings for behavioral healthcare organizations. Same trend for CMS surveys.  For psychiatric hospitals with deemed status, this can result in a Condition level finding and a 45 day follow-up survey. What follows for most organizations is a frenzy of revising treatment plan formats and re-training staff.

Common Pitfalls

So, the trend for survey findings in treatment planning is here to stay. The best defense is to know the key areas surveyors are scrutinizing. Then design your treatment planning formats and staff education to address those areas.

We reviewed our database to identify the major treatment planning issues surveyors are citing these days. They clearly cluster around problem statements, objectives, and interventions. For each of these areas, we’re sharing tips on how to design your treatment plans and avoid these survey pitfalls.

Problem Statements

Surveyors often cite that the problem statement is not written in behavioral terms and is not individualized.

Tips: A problem statement should substantiate the diagnosis and reflect the reason for admission. The problem statement should also include a problem description and be stated in behavioral terms.

To prompt staff to describe the patient’s behavior, it’s helpful to include the phrase “as evidenced by” in the problem statement. Examples: “Suicidal as evidenced by current thoughts of suicide, overdose prior to admission, feelings of hopelessness.” “Substance abuse as evidenced by history of cocaine abuse affecting job and relationship with family.”

A diagnosis by itself is not a problem statement; e.g. “Major Depressive Disorder.” There needs to be a description of the patient’s behavior. The one exception is that a diagnosis on Axis II can serve as a problem statement; e.g. “Uncontrolled Diabetes.”

Lastly, problem statements should not have multiple problems lumped together; e.g. “aggression and inappropriate sexual behavior.” These are two separate problems.

Objectives

Another common survey finding is that objectives are not written in behavioral terms and are not measurable. Also, staff frequently confuse objectives with interventions and intermingle these two concepts.

Tips: Objectives should be stated as patient behavior; i.e. what the patient will do. For example, “Patient will sit through at least one group per day without disruption.” “Patient will identify three stressors that trigger suicidal thoughts.” “Patient will verbalize at least 2 mindfulness skills for managing suicidal thoughts.” The objectives should relate directly to the problem statement.

Objectives should NOT describe what the staff will do. Several recent survey findings cited that the objectives were actually staff interventions, not patient behaviors. The non-compliant documentation included “Patient will be encouraged to attend group.” “Patient will be provided reinforcers for non-aggressive behavior.”

Surveyors also frequently cite that the objectives are general and do not relate to the patient’s individual problems. For example, “Patient will comply with meds, labs, and unit rules.” This could apply to all patients and is thus not individualized.

Also keep in mind the difference between long term goals vs. short term objectives. The long term goal is the goal the patient should achieve by discharge. The objectives are short term steps to achieve that long term discharge goal.

Interventions

Surveyors often cite interventions as not being individualized and lacking a focus for the intervention.

Tips: Interventions must be specific. They should not include routine, general care such as “administer medication.” The intervention should specify individual care for that patient and relate to the objective. Examples: “administer the following medications as ordered …..; educate patient on purpose and side effects; monitor patient’s response to meds.”

Interventions such as groups and individual therapy must also state the focus of the intervention. Examples: “OT will provide art group twice weekly to encourage concentration on task completion.” “Social worker will conduct 1:1 session weekly to discuss how behaviors related to psychosis affect quality of life, including …” “MD will meet 1:1 weekly to discuss level of agitation/aggression and effectiveness of medication in controlling aggression.”

Treatment Planning: Make it a Performance Improvement Project

We rarely see a survey report that does not include citations for treatment planning. It’s sort of the Holy Grail for the behavioral healthcare industry. However, we do see a difference with organizations that take the time and energy for a deep dive into their treatment planning process. They make it a focused PI project and include all the key stakeholders in the redesign. As a result, the end product is typically a more patient-centered treatment plan and fewer survey findings. A welcome outcome on both fronts!

Resources

For additional information on treatment planning requirements, check out the CMS Guidelines and our related posts on this topic:

• CMS State Operations Manual Appendix AA – Psychiatric Hospitals – Interpretive Guidelines and Procedures
• Treatment Plans in Psychiatric Hospitals
• Closed Medical Records Review: TJC Survey Feedback
• Update on TJC Survey Process for Psychiatric Hospitals

Learn more about our TJC survey preparation, Joint Commission continuous readiness, and CMS compliance support services.