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Based on record review and interview, the facility failed to provide psychosocial assessments that rendered conclusions and recommendations for the anticipated social worker's role in treatment for 6 of 16 active sample patients (A3, A23, C8, H18, H21 and L23). This failure results in a lack of documented recommendations for professional social work treatment services for use in the development of the treatment plan.

Findings include:

A. Record Reviews

1. The Core (Psychosocial) Evaluation dated 11/12/09 for Patient A3 recommended no social work treatment interventions.

2. The Core Evaluation dated 8/13/10 for Patient A23 recommended no social work treatment interventions.

3. The Core Evaluation dated 4/30/10 for Patient C8 recommended no social work treatment interventions.

4. The Core Evaluation dated 7/15/10 for Patient H18 recommended no social work treatment interventions.

5. The Core Evaluation dated 6/06/10 for Patient H21 recommended no social work treatment interventions.

6. The Core Evaluation dated 9/23/10 for Patient L23 recommended no social work treatment interventions.

B. Interview

In an interview on 10/5/10 at 10:00AM, the Social Work Director stated that the Core Evaluation is the psychosocial evaluation. She also explained that the facility uses a primary therapist model in which a psychologist, social worker, or nurse is assigned on a rotating basis to complete the Core Evaluation. Therefore, only those Core Evaluations completed by a Social Worker include the social work interventions. The Social Work Director corroborated the surveyor's findings regarding the Core Evaluations for Patients A3, A23, C8, H18, H21 and L23 and the absence of social work treatment methodology recommendations.

Based on record review and interview, the hospital failed to insure that the treatment plans included responsibilities for each member of the treatment team. Specifically, for 5 of 16 active sample patients (A3, C8, H18, H21 and L23), the treatment plans failed to delineate social work treatment interventions. This failure results in the facility's inability to monitor staff accountability for specific treatment interventions.

Findings include:

A. Record Reviews

1. The Treatment Plan dated 11/20/09 and last updated on 9/1/10 for Patient A3 identified no social work interventions.

2. The Treatment Plan dated 3/19/10 and last updated on 9/19/10 for Patient C8 identified no social work treatment interventions.

3. The Treatment Plan dated 8/20/10 and last updated on 8/20/10 for Patient H18 identified no social work interventions.

4. The Treatment Plan dated 6/08/10 and last updated 9/6/10 for Patient H21 identified no social work interventions.

5. The Treatment Plan dated 9/27/10 and last updated 9/27/10 for Patient L23 identified no social work interventions.

B. Interview

In an interview on 10/5/10 at 10:00AM, the Social Work Director corroborated the surveyor's findings. She explained that the facility uses a primary therapist model in which a psychologist, social worker or nurse is assigned on a rotating basis to complete the Treatment Plan. Only those treatment plans completed by the Social Worker include social work interventions.

Based on record review and interviews, the facility failed to insure the documentation of progress notes by the social worker for 5 of 16 active sample patients (A23, C8, H18, H21 and L23). This failure results in a lack of professional social work input into the evaluation of the treatment plan interventions.

Findings include:

A. Record Review

1. Review of all progress notes in the active record on 10/5/10 at 1:30PM for Patient A23 found no social work progress notes.

2. Review of all progress notes in the active record on 10/5/10 at 11:00AM for Patient C8 found no social work progress notes.

3. Review of all progress notes in the active record on 10/5/10 at 11:00AM for Patient H18 found no social work progress notes.

4. Review of all progress notes in the active record on 10/5/10 at 11:15AM for Patient H21 found no social work progress notes.

5. Review of all progress notes in the active record on 10/5/10 at 11:30AM for Patient L23 found no social work progress notes.

B. Interviews

In an interview on 10/5/10 at 10:00AM, the Social Work Director (SWD) stated that the social worker documents progress notes only when assigned as the primary therapist. She explained that the facility uses a primary therapist model in which a psychologist, social worker or nurse is assigned on a rotating basis to complete progress notes. She corroborated the surveyors' findings regarding the lack of social work progress note documentation for Patients A3, C8, H18, H21 and L23 based upon this facility model.

Based on record review and interview, the facility failed to provide a Social Work Director (SWD) who monitored and evaluated the quality and appropriateness of social services. This resulted in:

A) Psychosocial assessments which did not include recommendations for the social worker's role in treatment for 6 or 16 active sample patients, (A3, A23, C8, H18, H21 and L23);

B) Treatment plans that did not delineate social work treatment interventions for 5 of 16 active sample patients (A3, C8, H18, H21 and L23); and

C) Lack of progress note documentations for social work treatment interventions for 5 of 16 active sample patients (A23, C8, H18, H21 and L23).

The lack of social work oversight results in failure to identify and correct the absence of social work treatment recommendations on psychosocial assessments and social work methodologies on the treatment plans and lack of progress note documentation of social work treatment interventions for the treatment team's review.

Findings include:

A. Psychosocial assessments lacking recommendations for the social worker's role in treatment

1. Record Review

a. The Core (Psychosocial) Evaluation dated 11/12/09 for Patient A3 recommended no social work treatment interventions.

b. The Core Evaluation dated 8/13/10 for Patient A23 recommended no social work treatment interventions.

c. The Core Evaluation dated 4/30/10 for Patient C8 recommended no social work treatment interventions.

d. The Core Evaluation dated 7/15/10 for Patient H18 recommended no social work treatment interventions.

e. The Core Evaluation dated 6/06/10 for Patient H21 recommended no social work treatment interventions.

f. The Core Evaluation dated 9/23/10 for Patient L23 recommended no social work treatment interventions.

2. Interview

In an interview on 10/5/10 at 10:00AM, the Social Work Director (SWD) stated that the Core Evaluation is the psychosocial evaluation. She also explained that the facility uses a primary therapist model in which a psychologist, social worker or nurse is assigned on a rotating basis to complete the Core Evaluation. According to the SWD, the Core Evaluation would only recommend social work interventions if it was completed by the Social Worker. She corroborated the surveyor's findings regarding the Core Evaluations for Patients A3, A23, C8, H18, H21 and L23 and their absence of social work treatment methodology recommendations. The SWD also stated that she conducts no Quality and Appropriateness monitoring of Core Evaluations.

B. Treatment plans that do not delineate social work treatment interventions

1. Record Review

a. The Treatment Plan dated 11/20/09 and last updated on 9/1/10 for Patient A3 identified no social work interventions.

b. The Treatment Plan dated 3/19/10 and last updated on 9/19/10 for Patient C8 identified no social work treatment interventions.

c. The Treatment Plan dated 7/20/10 and last updated on 8/20/10 for Patient H18 identified no social work interventions.

d. The Treatment Plan dated 6/08/10 and last updated 9/6/10 for Patient H21 identified no social work interventions.

e. The Treatment Plan dated 9/27/10 and last updated 9/27/10 for Patient L23 identified no social work interventions.

2. Interview

In an interview on 10/5/10 at 10:00AM, the Social Work Director (SWD) corroborated the surveyor's findings. She explained that the facility uses a primary therapist model in which a psychologist, social worker or nurse is assigned on a rotating basis to complete the Treatment Plan. Only those plans completed by the Social Worker would identify social work interventions. The SWD stated that she conducts no Quality and Appropriateness monitoring of Social Work treatment interventions on treatment plans.

C. Lack of progress note documentation of social work treatment interventions

1. Record Review

a. Review of all progress notes in the active record on 10/5/10 at 1:30PM for Patient A23 found no social work progress notes.

b. Review of all progress notes in the active record on 10/5/10 at 11:00AM for Patient C8 found no social work progress notes.

c. Review of all progress notes in the active record on 10/5/10 at 11:00AM for Patient H18 found no social work progress notes.

d. Review of all progress notes in the active record on 10/5/10 at 11:15AM for Patient H21 found no social work progress notes.

e. Review of all progress notes in the active record on 10/5/10 at 11:30AM for Patient L23 found no social work progress notes.

2. Interviews

In an interview on 10/5/10 at 10:00AM, the Social Work Director (SWD) stated that the social worker documents progress notes only when assigned as the primary therapist. She explained that the facility uses a primary therapist model in which a psychologist, social worker or nurse is assigned on a rotating basis to complete progress notes. She corroborated the surveyors' findings regarding the lack of social work progress note documentation for Patients A3, C8, H18, H21 and L23 based upon this facility model. The SWD stated that she conducts no quality and appropriateness monitoring of any progress notes including those written by social workers.