Behavioral Health Treatment Plans

As George Harrison wrote in his song, Any Road, “…if you don’t know where you’re going, any road will take you there.” In healthcare, treatment plans are directive roadmaps intended to effectively advance patients through hospitalization. Treatment plans create a pathway of individualized, focused, and patient-centered actions that reflect the hospital’s commitment to provide effective care. Treatment plans serve as the pivotal point of care with assessments and reassessments informing and reforming the plan accordingly. In this way, treatment plans are living, breathing documents that bring a multidisciplinary team together in a collaborative manner so that their expert interventions help patients achieve short and long-term goals.

Maintaining consistent compliance with behavioral health treatment plans can be challenging. Compliant treatment plans require continuous attention to detail and diligence with timeliness. Treatment plans need to be clearly individualized to each patient with updates documented as changes occur. In this article, we will review the Centers for Medicare and Medicaid Services (CMS) requirements of treatment planning as explained through the Interpretive Guidelines with key considerations and observations from the field. When reviewing your organization’s compliance with CMS regulations, it is important to use the CMS Interpretive Guidelines to fully evaluate the detailed expectations of each tag.

Key Requirements and Considerations

 Individualization of Treatment Plan   

1. With CMS A-1640, the expectations for treatment plan start by describing a comprehensive plan that is individualized based on the patient’s strengths and disabilities. CMS notes that facilities can use their own treatment plan formats, and the term “disability” can be exchanged with “problem.” There needs to be documentation of a regular review of the patient’s response to interventions and progress toward goals at an appropriate frequency determined by the hospital. The treatment plan should be revised accordingly to facilitate the patient’s progress. As noted above, the Interpretive Guidelines reveal how these requirements will be surveyed. Key considerations and observations include:

• Check for the regular attendance of treatment team members in reviewing the patient’s plan and progress. Various members of the multidisciplinary team should be consistently present to express their updates.
• Importantly, is the treatment plan individualized to the patient or is there a “predictable sameness” with other treatment plans in which goals and interventions are not specific to the patient? One of the best ways to determine if a treatment plan is individualized enough is to cover the patient identifying label and ask staff if they could identify the patient only by the details of the problems, goals, and/or interventions. For example, a patient is experiencing significant stress from family conflict that causes agitation as evidenced by pacing, raised voice, and refusal to attend group after a family session. Does the treatment plan reflect these details? Do the interventions and goals reflect details for how the team is collaborating therapeutically with the patient to work through this conflict? Lack of this type of individualization is one of the most common survey findings.

Substantiated Diagnosis

2. CMS A-1641 states the treatment plan must have a substantiated diagnosis that is the focal point of treatment. The substantiated diagnosis comes from the completion of the history and physical, psychiatric evaluation, and other assessments. The treatment plan should identify problems that are described with specific details and behaviors rather than generalized statements. CMS provides examples of noncompliant, generalized terms such as “paranoid” and “aggressive.” Key considerations and observations include:

• Are all active problems that are receiving treatment – behavioral and medical – included in the treatment plan? A frequent survey finding is an active medical problem that is not included in the treatment plan. For example, if a patient has hypertension and is receiving an antihypertensive, a problem sheet on hypertension should be included even if the patient’s blood pressure is stable. An effective strategy is to review all the behavioral and medical problem sheets during treatment team meetings to verify that all active problems are being appropriately addressed.

Short Term & Long-Range Goals

3. The next CMS tag is A-1642 regarding short-term and long-range goals. Depending on the expected length of patient stay, short-term goals may only be needed or short and long-range goals will both be needed. It is important to have specific dates listed, updated, and discontinued (closed out) depending on the patient’s progress. Short-term goals can be considered as building blocks for long-range goals that may include discharge conditions. Goals need to be measurable with observable behaviors. Key considerations and observations include:

• Upon chart review, we frequently observe short-term and long-range goal dates as expired. Changes in condition do not prompt goals to be amended or extended can result in a survey finding.
• Do goals reflect what the patient will achieve (as opposed to interventions that indicate what the staff will do)?

Multi-Disciplinary- Interdisciplinary Team Care Delivery

4. CMS tag 1643 pertains to modalities which is the treatment the patient is receiving as provided by various members of the treatment team. It is important to note that this standard is not met by simply listing the group schedule of activities such as activity therapy; the focus on the activity needs to be included. For example, when process group is provided as a morning activity, what is the specific focus for the patient? In our preceding example of the patient who was experiencing family conflict, the focus of the morning process group may be in applying stress management techniques prior to his family session to decrease agitation. Key considerations and observations include:

• Can the staff articulate the focus of the modalities?
• Are modalities scheduled and provided to the maximum benefit of patients?
• Does the patient understand the treatment plan and how is s/he engaged in participating? Is there evidence of this understanding such as his or her signature of understanding/agreement on the treatment plan?

Responsibilities of the treatment team

5. Following treatment modalities is A-1644 on the responsibilities of each treatment team member. CMS states there is no required number of treatment team members. The number depends on the identified problems, scope of goals, and treatment. An important aspect of this requirement is the documentation of the staff member who is responsible for the specific treatment. Typically, this requirement will be documented as the first initial or first name, last name, credential, and discipline. Key considerations and observations include:

• Double check for staff’s name, credentials, and discipline on interventions. This easy-to-miss requirement can lead to a survey finding.

Patient Response to the treatment plan

6. As the treatment plan is carried out, it is important to document these efforts and the patient’s responses. A-1645 concerns the interdisciplinary documentation that substantiates the diagnosis and the treatment that is being provided. Progress notes should reference the treatment plan’s problems such as nursing note documentation of a patient’s response to an antihypertensive medication. Key considerations and observations include:

• Upon review of interdisciplinary notes, how do progress notes connect back to the interventions of nursing, social work, medical, and activity therapists? Are the treatment plan problems referenced?

  Active Treatment

7. Lastly, A-1650 is the final requirement related to treatment planning and concerns the importance of active treatment. In the Interpretive Guidelines, CMS notes, “Active treatment is an essential requirement for inpatient psychiatric care.” Documentation of active treatment provides justification that 24-hour care is required for the safety of patient as opposed to a less intensive level of care. It is important to review all the requirements of A-1650 as findings under this tag could be noted substantial enough to result in a condition-level finding and refers to the critical protection of patient rights. Active treatment must be provided as noted in the treatment plan with available alternative activities if the patient cannot participate for any reason. Key considerations and observations include:

• If restraint or seclusion is used, is this event included in the treatment plan? What interventions are included to minimize continued use of restraint and seclusion? The omission of restraints and seclusions on the treatment plan is often noted as a survey finding. An effective strategy to avoid this finding is to include an audit of the treatment plan when the restraint and seclusion packet is audited (preferably in real-time).
• Is the patient well-informed of his or her treatment plan? Is there documented evidence of the protection of his or her rights?
• Are changes such as with medications documented with information provided to the patient?

Summary

Effective treatment plans drive expert interventions that help patients to recover through engagement and collaboration. When treatment plans are thorough and focused, healthcare organizations create decisive roadmaps from a patient’s admission through a timely discharge. While treatment plans require significant detail and updates, organizations can achieve success through review of requirements, diligent auditing, and interdisciplinary communication.

Resource

State Operations Manual Appendix A - Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals Table of Contents (Rev. 200, 02-21-20). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

To learn more about Behavioral Health Treatment Plans contact the Courtemanche and Associates Team at 704-573-4535 or email us at info@courtmanche-assocs.com.