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Based on record review, interview and audit records, the hospital failed to provide social work assessments that include a plan and recommendations of the anticipated necessary steps for discharge to occur, specific community resources, support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning in three (3) of eight (8) records reviewed (A2, A4 and A6).

Findings include:

RECORD REVIEW

1. Patient A2 was admitted 4/18/16 and the "Psychosocial Assessment" was completed 4/18/16. The assessment summary included the following: "1st contact for a single 27 y.o. unemployed female LS302B for person described as suicidal. Patient lives with her parents and can return. She does not attend therapy currently. Objective: Patient will have a three minute reality based conversation with tx team member daily. Intervention: Discuss realistic discharge plans and link with family as permitted. Objective: Patient will allow parents to be involved in her treatment by signing release of information for parents. Intervention: Present release of information forms and encourage patient to allow family to be involved."

2. Patient A4 was admitted 4/19/16 and the Psychosocial Assessment was completed 4/20/16.
The assessment summary included the following: "Pt is a 54 y.o. SWF that has her 2nd contact with MCES. Pt was admitted to MCES on a 302A legal status due to being +SI, making threatening statements and being aggressive towards family. The hope is when at MCES patient will be able to gain insight into her behaviors prior to ??. There were no social work objectives or interventions reflected in the master treatment plan dated 4/21/16."

3. Patient A6 was admitted 4/15/2016 and the Psychosocial Assessment was completed 4/17/16.
The assessment summary included the following: "First contact at MCES for a 23 y.o. white male admitted via LS302 for person described as threatening. Social work documentation on the treatment plan included the following: Objective 2.1 patient will identify 3 alternative strategies to safely cope with the ill feeling about himself or family members. This objective led to an intervention of: Encourage patient to maintain appropriate behaviors on the unit and reconnect him with appropriate outpatient services."

INTERVIEW

A meeting was held on April 27, 2016 with the Director of Social Work who validated the survey findings.

AUDIT REPORTS

Audits were initiated in March to monitor the changes made in Social Work in response to the POC.

Four items were identified for record review and audit. These items are: 1) Psychosocial Assessment completed, 2) Sufficient conclusion of findings regarding discharge barriers and needs in PSA, 3) Description of social worker's role in treatment and discharge planning in PSA, 4) If PSA not completed, three documented attempts to complete on form and all attempts documented in the progress notes.

Findings for the month of March were: The first item showed a compliance rate of 99.3%, the second item showed a compliance rate of 71%, the third item showed a compliance rate of 38.7%, and the fourth item showed a compliance rate of 50%.

Findings for the first two weeks of April were: The first item showed a compliance rate of 100%, the second item showed a compliance rate of 93.3%, the third item showed a compliance rate of 33.3%, and the fourth item showed a compliance rate of "N/A."

Based on record review, interview and audit review, the Director of Social Work failed to:

Ensure social work assessments that contain conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge for three of eight sample patients (A2, A4, and A6). As a result the treatment team did not have necessary social work information including conclusions and recommendations to utilize in developing treatment goals and interventions. (Refer to B108)

Findings include:

RECORD REVIEW

1. Patient A2 was admitted 4/18/16 and the "Psychosocial Assessment" was completed 4/18/16. The assessment summary included the following: "1st contact for a single 27 y.o. unemployed female LS302B for person described as suicidal. Patient lives with her parents and can return. She does not attend therapy currently. Objective: Patient will have a three minute reality based conversation with tx team member daily. Intervention: Discuss realistic discharge plans and link with family as permitted. Objective: Patient will allow parents to be involved in her treatment by signing release of information for parents. Intervention: Present release of information forms and encourage patient to allow family to be involved."

2. Patient A4 was admitted 4/19/16 and the Psychosocial Assessment was completed 4/20/16.
The assessment summary included the following: "Pt is a 54 y.o. SWF that has her 2nd contact with MCES. Pt was admitted to MCES on a 302A legal status due to being +SI, making threatening statements and being aggressive towards family. The hope is when at MCES patient will be able to gain insight into her behaviors prior to ??. There were no social work objectives or interventions reflected in the master treatment plan dated 4/21/16."

3. Patient A6 was admitted 4/15/2016 and the Psychosocial Assessment was completed 4/17/16.

The assessment summary included the following: "First contact at MCES for a 23 y.o. white male admitted via LS302 for person described as threatening. Social work documentation on the treatment plan included the following: Objective 2.1 patient will identify 3 alternative strategies to safely cope with the ill feeling about himself or family members. This objective led to an intervention of: Encourage patient to maintain appropriate behaviors on the unit and reconnect him with appropriate outpatient services."


INTERVIEW

A meeting was held on April 27, 2016 with the Director of Social Work who validated the survey findings.

AUDIT REPORTS

Audits were initiated in March to monitor the changes made in Social Work in response to the POC.

Four items were identified for record review and audit. These items are: 1) Psychosocial Assessment completed, 2) Sufficient conclusion of findings regarding discharge barriers and needs in PSA, 3) Description of social worker's role in treatment and discharge planning in PSA, 4) If PSA not completed, three documented attempts to complete on forms and all attempts documented in the progress notes.

Findings for the month of March were: The first item showed a compliance rate of 99.3%, the second item showed a compliance rate of 71%, the third item showed a compliance rate of 38.7%, and the fourth item showed a compliance rate of 50%.

Findings for the first two weeks of April were: The first item showed a compliance rate of 100%, the second item showed a compliance rate of 93.3%, the third item showed a compliance rate of 33.3%, and the fourth item showed a compliance rate of "N/A."