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Based on record review and interview, the facility failed to inform the patient's representative, who was the patient's Durable Mental Health Care Power of Attorney (POA), by keeping them informed of Patient #1's (Pt #1) mental heath care status and impending discharge plans. Consequently, the patient's representative was unable to make informed decisions regarding her mother's care during her stay in the facility and subsequent discharge (refer to A - 0131).

The cumulative effect of this systemic practice resulted in the hospital's inability to ensure that the patient rights and their representatives were able to make informed consents and decisions. This deficient practice of not providing information to the POA regarding the Pt #1 mental health care status and impending discharge, resulted in Pt #1's discharged from the facility but failed to arrived to her intended destination. Pt. #1 ended up in the emergency department of a hospital en route to her final destination in a dehydrated and psychotic state.

Based on record review and interviews, the facility failed to inform the patient's representative, who was the patient's durable mental health care Power of Attorney (POA), of Patient #1's (Pt #1) mental heath care status and impending discharge plans that would enable her to make informed decisions regarding her mother's care during her stay in the facility for 1 (Pt #1) of 3 sampled Patients (Pt #'s 1 - 3) reviewed for patient's rights. This deficient practice of not providing information to the POA regarding the Pt #1's mental health care status and impending discharge, resulted in Pt #1 being discharged from the facility on 05/30/19, and not making it to her intended destination in stable condition. The findings are:

A. Record review of Pt #1's medical record revealed the following:

1. The Psychiatric Evaluation dated 05/26/19, indicated the following: "The patient is a 64-year-old female, who states that she was admitted from the [Name of local Healing Center] secondary to the doctor's concerns with regard to her mood and "mania." The patient states that she resides with her daughter and her daughter out of concern for the patient's safety...[was] admitted to [Name of local Healing Center]. Per the patient, this was to help keep her safe as well as to help with her overall mood and instability...She then further elaborates by stating that the facility staff became concerned when yesterday she "bought a condominium." She therefore was transferred again voluntarily to the facility for ongoing medication management and monitoring...patient has been hospitalized at least 5 times in the last 5 years for "what patient describes as emotional deprivation." She has also in the past attempted suicide on psychotropic medications while drinking alcohol. She has also been in a coma for 3 days with several of the patient's past hospitalizations being court ordered...The patient does have a power of attorney for her mental health and this is her daughter..."

2. The Admission History and Physical Examination dated 05/26/19, revealed the following diagnoses: "...history of Bipolar 2 [A type of bipolar disorder characterized by depressive (experiencing a deep sadness or hopelessness) and hypomanic (characterized by persistent disinhibition and mood elevation) episodes. It involves at least one depressive episode lasting at least two weeks and at least one hypomanic episode lasting at least four days.], TBI [Traumatic Brain Injury, a brain dysfunction caused by an outside force, usually a violent blow to the head], HTN [hypertension, having high blood pressure], PTSD [Post Traumatic Stress Disorder, a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it] and seasonal allergies...She began to refuse her medications [while at the Healing Center] and started to become allegedly manic. Fighting with staff and residents. She was transferred to the facility for psychiatric management.
Past Medical History: PTSD, Bipolar 2, Manic, TBI, EDD [Emotional Deprivation Disorder, a deprivation of love during childhood development] and Delusions of grandeur [a false sense or unusual belief about one's greatness]..."


B. On 07/18/19 at 9:56 am, during an interview, Pt #1's POA confirmed that she had been given the decision making authority for Pt #1 through a dated, signed, and notarized Durable Mental Health Care Power of Attorney from the State of Arizona. She confirmed that she did not receive any communication (no letters, no phone calls, no emails, etc.) from the Social Worker at the facility regarding Pt #1's care and impending discharge.


C. Record review of Pt #1's Durable Mental Health Care Power of Attorney from the State of Arizona dated 05/03/19, revealed the following: "...Mental health treatment that I AUTHORIZE if I am unable to make decisions for myself: ...I authorize my mental health care representative to make on my behalf if I become incapable of making my own mental health care decisions due to mental or physical illness, injury, disability, or incapacity. If my wishes are not clear from this Durable Mental Health Care Power of Attorney or are not otherwise known to my representative, my representative will, in good faith, act in accordance with my best interests...

My representative is authorized to do the following which I have initialed or marked:

A. About my records: To receive information regarding mental health treatment that is proposed for me and to receive, review, and consent to disclosure of any of my medical records related to that treatment.

B. About medications: To consent to the administration of any medications recommended by my treating physician.

C. About a structured treatment setting: To admit me to a structured treatment setting with 24 hour-a-day supervision and an intensive treatment program licensed by the Department of Health Services, which is called an inpatient psychiatric facility..."


D. Record review of the Nursing Reassessment - Day [Shift] dated 05/30/19 [day of discharge], revealed the following: "0900 - 05/30/19 - Up pacing hall, using portable phone, stated, 'My husband stole my credit card. I don't have any money now," Social worker here and spoke with client. Client med compliant and cooperative with unit routine, possible discharge today. SW working on details. 1600 [4:00 PM] Client discharged in stable condition, ambulatory, all personal property given to client meds, clothing, verbalize understanding of discharge and follow up."


E. Record review of the Psychiatric Progress Note dated 05/29/19, revealed the following:

"CHIEF COMPLAINT: 'I need to speak to the social worker, [Name of SW #1] as she is helping me with discharge to Phoenix. Lamictal is working well for my mania. I'm not depressed at all.'

INTERVAL HISTORY: The patient was admitted on May 25, 2019, from the [Name of a Health Center] in Santa Fe...The patient states that she is not sleeping well, but she does not want any of her medications changed. She continues to journal and is talking of her husband, who is quite abusive to her in the past. She stresses the 'abusive' part. Staff report that she is calmer than she had been. She follows me around on the unit. She continues take her medications and participate in group. Her appetite is at her baseline...

VITAL SIGNS: Blood pressure 102/68, pulse is 117 [average pulse rate between 60-100], respiratory rate 18...Hours slept 5.25. She is tidy. She is ambulatory.

MENTAL STATUS EXAMINATION: She is oriented x 4. Her attention and concentration on a one-to-one are good. Memory, remote and recent really cannot ascertain. Speech is pressured [is an accelerated or frenetic pace that conveys urgency seemingly inappropriate to the situation. It is often difficult for listeners to interrupt pressured speech, and the speech may be too rapid to understand.] Mood and affect are focused on being discharged and needing credit cards and new place to reside in Phoenix. Thought process is focused on new credit cards, new place to reside. Associations are tangential [is a communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation.] She has a flight of ideas...Insight and judgement are impaired...The patient meets inpatient criteria secondary for ongoing medication management and adjustment as well as concern for the danger of herself..."


F. On 12/04/19 at 3:15 PM, during an interview, Social Worker [SW #1, who has worked at the facility since March 2019] when asked if at any time during Pt #1's hospital stay [05/26/19 through 05/30/19], did she call Pt #1's daughter, since she was the POA. She replied, "No." She further stated that it was her understanding that it was the Psychiatrist that "turns-on" the POA for someone to be capable of handling their own affairs. But that didn't happen... She [Pt #1] told me not to call her daughter. SW #1 stated that when she did talk with Pt #1's daughter which was on the day that Pt #1 was going to be discharged from the facility on 05/30/19. She said that Pt #1 was talking on phone with her daughter, who then gave the phone over to her [meaning SW #1] and that the daughter was 'brow-beating me.' She further stated, "I got kinda stressed and I told her that I can't have this conversation with her and I terminated the call." When asked if she had hung- up the phone on the daughter, SW #1 replied, "I terminated the call."


G. On 12/05/19 at 11:15 am, during an interview, SW #2 [who has worked at the facility for over 2 years], when asked as the SW, would she contact the POA of patients at the facility, if they had a Durable Mental Health Care POA. She stated, "Yes." When asked even if the Psychiatrist says to notify the POA or not, SW #2 stated that it wouldn't matter what the doctor says, the Durable Mental Health Care POA document is in the chart for a reason. It is a legal document that should be honored. SW #2 stated, "I would call the POA, whether the patient wanted me to or not. I would explain to the patient the reasons why I needed to call them." SW #2 reviewed Pt #1's Durable Mental Health Care POA from the State of Arizona, she stated that usually on a Care POA there would be an expiration date on the document. That the Durable Mental Health Care POA has a limited time attached to it. In this case, she said, I would either call the of Office of the Arizona Attorney General or I would call the POA to find out the expiration date. SW #2 stated that either way, she would definitely call the POA to keep them informed.


H. Record review of the Social Services Progress Note dated 05/14/19 [Pt #1 was not admitted to the hospital until 05/26/19. This was confirmed by the Chief Executive Officer (CEO), the date should have indicated 05/30/19], revealed the following: "[Name of Patient #1] wants to return to Phoenix and stay with a friend. Social worker purchased a bus ticket and made her doctor appointments in Phoenix. Right before patient left, it turned out she had lost her wallet and ID. However, she was able to get on the bus without it. She spoke to her daughter right before she left about picking her up in Phoenix. Daughter refused to pick mother up and became very angry that patient was discharging without her consent. Daughter feels mother is too ill to discharge. Daughter claimed to be Medical Power of Attorney (no record of that in client chart), and called the nursing station several times over the course of the evening demanding to know what bus client was on and threatening to sue the facility if anything happened to her mother..."


I. Record review of the facility's policy titled "Patient Rights," last approved 02/2019, revealed the following: "...every patient, or his designate representative, where appropriate shall have the opportunity to participate to the fullest extent possible in planning for his care and treatment..."

Based on record review and interview, the facility failed to employ a staff person who was appropriately trained and qualified to provide discharge planning evaluations to determine discharge needs which affects all patients. This deficient practice resulted in poor discharge planning, which resulted in the following:

1. Patient #1 being discharged from the facility, with only $6.00 in her pocket, no photo identification, no medications, no food, or water. Patient #1 was found in the emergency department of a hospital in another city on the bus route, not Pt #1's destination. Pt #1 was found to have not eaten, was dehydrated and in a deep psychosis (refer to A - 0818);

2) Failed to ensure that the patient and family members or interested persons were included in the discharge planning for post-hospital care (refer to A - 0820). The Pt #1 was discharged from the facility with no information provided to her what to do when there were concerns, issues, or problems that arose during her bus trip from Albuquerque to Phoenix. Patient #1 was found in an emergency room in Flagstaff, AZ when Pt #1's daughter and family tracked her down. Patient #1 had not eaten, was dehydrated, and in a deep psychosis. Patient #1 did not arrive at her destination in Phoenix as planned.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to ensure that the discharge planning process was appropriate and that there was a smooth and safe transition from the hospital to Patient #1's discharge destination.

Based on interview and record review, the facility failed to employ a staff person who was appropriately trained and qualified to provide discharge planning evaluations to determine discharge needs of patients. This deficient practice resulted in poor discharge planning, which resulted in Patient #1 discharged from the facility with only $6.00 in her pocket, no photo identification, no medications, no food, or water. Patient #1 was found her family in the emergency room of a hospital in a city on the bus route, which was not her final destination. Pt #1 was found to have not eaten, was dehydrated and in a deep psychosis [meaning that an individual has sensory experiences of things that do not exist and/or beliefs with no basis of reality. The findings are:


A. On 12/04/19 at 3:17 PM, during an interview, Social Worker #1 [SW #1] who has been employed by the hospital since 03/25/19 and had previously worked at a local psychiatric facility for 2 years. SW #1 stated that as the discharge planner there was so much to learn, that there was a steep learning curve. She stated that she has learned by leaps and bounds. She stated that now, as opposed to the end of May, she has a different idea of what resources exist in New Mexico. SW #1 stated that during a telephone call that she had with Pt #1's daughter, SW #1 felt that the daughter was brow-beating her. She stated, "I got kinda stressed," I told the daughter, "I can't have this conversation with her, so I terminated the call." When asked if she hung-up on her, SW #1 replied, "I terminated the call."

SW #1 stated that she felt that the complaint investigation focus was being improperly put on her. She stated, "every day we have a treatment team meeting, we discuss the patient's insurance and what is happening with the patient." SW #1 stated that when Pt #1 first arrived at the facility, she was very demanding, she said she mellowed and her personality changed, she was able to participate in group therapy..."During the course of the week, I saw the change in her [being Pt #1]," said SW #1. SW #1 further stated, "as we went on, Pt #1 participated appropriately and was able to tell me what she wanted...she was afraid of her daughter [who was the Power of Attorney] and ex-husband." SW #1 further stated that Pt #1 had stated to her "They [her daughter and husband] want to run my life."

When asked if she had read the discharge summary from Pt #1's previous hospitalization, SW #1 replied, "No." When asked if she had talked with her supervisor regarding Pt #1's discharge, SW #1 stated, "As far as I know, I did go internally. No one told me that I did wrong. Now I'm paranoid and fearful. What could the ramifications be? I'm not gonna say it's my fault. There is literally nothing else I can tell you. I don't know if there's anything else I could have done. I'm not gonna talk about this with my manager because he has left. Now, I run to our temporary manager with everything. SW #1 stated, "I'm the one who goes overboard on everything. Even if it should be self-evident."

When asked if the patient is included in the discharge plan, SW #1 responded, "Yes, absolutely." What about the POA [Power of Attorney]? SW #1 stated, "See, this is the part that's unclear to me. The patient tells me who I'm able to talk to." When asked if she contacts the POA to be part of the discharge, she said, "You're darn tootin'." When asked if her discussions with Pt #1 were documented, she said, "No, but it should be, I usually make a note on the PSA [Psycho-Social Assessment]." SW #1, when asked if she had documented any discussions with Pt #1, regarding her POA, said Pt #1 specifically said, "No, don't call my daughter." SW #1 stated, "I don't know if that is in my notes."

In regards to SW #1's training on discharge planning at the facility, she stated, "No. I never was trained. To be honest, I was kind of thrown into it. It takes a long time to get up to speed. You learn as you go. It was frustrating working with that supervisor [the previous supervisor, who no longer works in the facility]. She further stated, "We don't have time to track down the doctors, they're very busy. I honestly believed I was following self-determination [Pt #1's choice of discharge]. The POA was not invoked. At the time, I was doing as I thought was appropriate."


B. On 12/05/19 at 11:15 am, during an interview, SW #2, who has worked at the facility for over 2 years, stated that it would not matter to her, if the patient said, "Don't call my daughter [being the POA] or the physician invoking the POA. I would call the courts to determine if the Durable Mental Health Care POA was limited or had it expired. Pt #1's Durable Mental Health Care POA was in effect as of 05/03/19." She confirmed that SW #1's training should have been better. She stated that the training of SW's has been inconsistent since last November, which has affected the last two employees that we have hired, one being SW #1. She stated that if she was discharging a patient, who had no identification, she would make-up temporary identification. She also stated that she would have provided Pt #1 with a bag of groceries, that would have included a lunch sack from the facility, some granola bars and snacks, and bottled water. There have been times that we have filled their medication prescription. She stated that some of those bus rides are quite long, the bus ride from Albuquerque to Phoenix was an 8 hour and 55 minute average bus ride. SW #2 stated that when she first started working at the hospital, the SW was not given a case-load of patients until they were thoroughly trained. In regards to the Durable Mental Health Care POA, SW #2 stated that Pt #1 and her daughter [the POA] must have felt at the beginning of May, that this Durable Mental Health POA document should be put into place, or else Pt #1 would not have signed it. SW #2 stated, "The Durable Mental Health Care POA was a document to be considered, it is a legal document, which was notarized."


C. Record review of the Social Services Progress Note dated 05/14/19 [Pt #1 was not admitted to the hospital until 05/26/19. This was confirmed by the Chief Executive Officer (CEO), the date should have indicated 05/30/19], revealed the following: "[Name of Patient #1] wants to return to Phoenix and stay with a friend. Social worker purchased a bus ticket and made her doctor appointments in Phoenix. Right before patient left, it turned out she had lost her wallet and ID. However, she was able to get on the bus without it. She spoke to her daughter right before she left about picking her up in Phoenix. Daughter refused to pick mother up and became very angry that patient was discharging without her consent. Daughter feels mother is too ill to discharge. Daughter claimed to be Medical Power of Attorney (no record of that in client chart), and called the nursing station several times over the course of the evening demanding to know what bus the client was on and threatening to sue the facility if anything happened to her mother..."

D. Record review of the Pt #1's medical record, there was no documentation that the facility was concerned that Pt #1's daughter thought that her mother was not stable or well to be discharged. The facility continued to discharge Pt #1, in spite of what the daughter thought and relayed to the SW.

E. Record review of the Social Worker Job Description was signed by SW #1 on 03/25/19. The Job description revealed the following: "Position Summary: Assesses and evaluates assigned patients. Conducts individual, family, and/or group therapy. Functions as the primary contact for treatment and discharge planning. Promotes implementation of therapeutic milieu and daily program schedule. Maintains a safe and efficient working and treatment environment per facility policies and procedures. Communicates effectively with the treatment team to ensure safe, quality care is provided to all patients...Discharge Planning: Assume an active role in discharge planning by identifying barriers to discharge during initial assessment and ongoing interactions with the patient and family. Formulate discharge plan in coordination with the treatment team, patient, family, and outside agencies as appropriate. Establish and maintain cooperative relations with community agencies and other resources...Customer Service:...Act to preserve patient and family dignity and safety. Documentation: Documentation for medical records and reports is timely, legible, thorough, and in required format. Document as required including assessments, interventions, treatment plan, discharge planning, and incident reports. Create, update and revise treatment plan as assigned and per policy..."

Based on record review and interview, the facility failed to ensure that the patient and family members were included in the discharge palnning in preparation for post-hospital care for 1 [Patient #1] of 3 sampled discharged patients [Patient #'s 1 - 3] reviewed for discharge planning. This deficient practice resulted in Pt #1 was not provided information what to do when there were concerns, issues, or problems that arose during her bus trip from Albuquerque to Phoenix when discharged. Patient #1 was found in the emergency room in Flagstaff, AZ, a city on the bus route from Albuquerque to Phoenix, AZ, when Pt #1's daughter and family tracked her down. Patient #1 did not arrive at her destination in Phoenix as planned. The findings are:

A. Record review of Patient #1's Discharge/Aftercare Instructions dated 05/30/19, revealed the following discrepancies:

1. Under Disposition: Indicated as the discharge location, a friend's home in Phoenix was indicated with no address;

2. Transportation Arrangement: Greyhound was indicated;

3. Aftercare Instructions indicated as provided by Nursing: Section was blank;

4. Social Services: Emergency/Crisis Planning & Risk Factors: Patient's reason for admission: Manic episode. Professionals or agencies I can contact during a crisis: Call my therapist: nothing was indicated, Call my family doctor [Primary Care Physician, PCP: [Name of family doctor] [legibility], Suicide Prevention Lifeline: 800 phone number was provided, Instructions to Call 911 and Go to the nearest Emergency Department.


B. On 07/18/19 at 9:56 am, during an interview, Pt #1's POA confirmed that she had been given the decision making authority for Pt #1 through a dated, signed, and notarized Durable Mental Health Care Power of Attorney from the State of Arizona. She confirmed that she did not receive any communication (no letters, no phone calls, no emails, etc.) from Social Worker at the facility regarding Pt #1's care and impending discharge.


C. On 12/04/19 at 3:15 pm, during an interview, Social Worker [SW #1, who has worked at the facility since March 2019] when asked if at any time during Pt #1's hospital stay [05/26/19 through 05/30/19], did she call Pt #1's daughter, since she was the POA. She replied, "No." She further stated that it was her understanding that it was the Psychiatrist that "turns-on" the POA for someone to be capable of handling their own affairs. But that didn't happen...She [Pt #1] told me not to call her daughter. SW #1 stated that when she did talk with Pt #1's daughter which was on the day that Pt #1 was going to be discharged from the facility on 05/30/19. She said that Pt #1 was talking on phone with her daughter, who then gave the phone over to her [meaning SW #1] and that the daughter was 'brow-beating me. She further stated, "I got kinda stressed and I told her that I can't have this conversation with her and I terminated the call." When asked if she had hung- up the phone on the daughter, SW #1 replied, "I terminated the call."


D. Record review of the Nursing Reassessment - Day [Shift] dated 05/30/19 [day of discharge], revealed the following: "0900 - 05/30/19 - Up pacing hall, using portable phone, stated, 'My husband stole my credit card. I don't have any money now," Social worker here and spoke with client. Client med compliant and cooperative with unit routine, possible discharge today. SW working on details. 1600 [4:00 pm] Client discharged in stable condition, ambulatory, all personal property given to client meds, clothing, verbalize understanding of discharge and follow up."


E. Record review of the Psychiatric Progress Note dated 05/29/19, revealed the following:

"CHIEF COMPLAINT: 'I need to speak to the social worker, [Name of SW #1] as she is helping me with discharge to Phoenix. Lamictal is working well for my mania. I'm not depressed at all.'

INTERVAL HISTORY: The patient was admitted on May 25, 2019, from the [Name of a Health Center] in Santa Fe...The patient states that she is not sleeping well, but she does not want any of her medications changed. She continues to journal and is talking of her husband, who is quite abusive to her in the past. She stresses the 'abusive' part. Staff report that she is calmer than she had been. She follows me around on the unit. She continues take her medications and participate in group. Her appetite is at her baseline...

VITAL SIGNS: Blood pressure 102/68, pulse is 117 [average pulse rate between 60-100], respiratory rate 18...Hours slept 5.25. She is tidy. She is ambulatory.

MENTAL STATUS EXAMINATION: She is oriented x4. Her attention and concentration on a one-to-one are good. Memory, remote and recent really cannot ascertain. Speech is pressured [is an accelerated or frenetic pace that conveys urgency seemingly inappropriate to the situation. It is often difficult for listeners to interrupt pressured speech, and the speech may be too rapid to understand.] Mood and affect are focused on being discharged and needing credit cards and new place to reside in Phoenix. Thought process is focused on new credit cards, new place to reside. Associations are tangential [is a communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation.] She has a flight of ideas...Insight and judgement are impaired...The patient meets inpatient criteria secondary for ongoing medication management and adjustment as well as concern for the danger of herself..."


F. On 12/04/19 at 3:15 pm, during an interview, Social Worker [SW #1, who has worked at the facility since March 2019] when asked if at any time during Pt #1's hospital stay [05/26/19 through 05/30/19], did she call Pt #1's daughter, since she was the POA. She replied, "No." She further stated that it was her understanding that it was the Psychiatrist that "turns-on" the POA for someone to be capable of handling their own affairs. But that didn't happen...She [Pt #1] told me not to call her daughter. SW #1 stated that when she did talk with Pt #1's daughter which was on the day that Pt #1 was going to be discharged from the facility on 05/30/19. She said that Pt #1 was talking on phone with her daughter, who then gave the phone over to her [meaning SW #1] and that the daughter was 'brow-beating me. She further stated, "I got kinda stressed and I told her that I can't have this conversation with her and I terminated the call." When asked if she had hung- up the phone on the daughter, SW #1 replied, "I terminated the call."


G. On 12/05/19 at 11:15 am, during an interview, SW #2 [who has worked at the facility for over 2 years], when asked as the SW, would she contact the POA of patients at the facility, if they had a Durable Mental Health Care POA. She stated, "Yes." When asked even if the Psychiatrist says to notify the POA or not, SW #2 stated that it wouldn't matter what the doctor says, the Durable Mental Health Care POA document is in the chart for a reason. It is a legal document that should be honored. SW #2 stated, "I would call the POA, whether the patient wanted me to or not. I would explain to the patient the reasons why I needed to call them." SW #2 reviewed Pt #1's Durable Mental Health Care POA from the State of Arizona, she stated that usually on a Care POA there would be an expiration date on the document. That the Durable Mental Health Care POA has a limited time attached to it. In this case, she said, I would either call the of Office of the Arizona Attorney General or I would call the POA to find out the expiration date. SW #2 stated that either way, she would definitely call the POA to keep them informed.


H. Record review of the Social Services Progress Note dated 05/14/19 [Pt #1 was not admitted to the hospital until 05/26/19. This was confirmed by the Chief Executive Officer (CEO) on 12/05/19, the date should have indicated 05/30/19], revealed the following: "[Name of Patient #1] wants to return to Phoenix and stay with a friend. Social worker purchased a bus ticket and made her doctor appointments in Phoenix. Right before patient left, it turned out she had lost her wallet and ID. However, she was able to get on the bus without it. She spoke to her daughter right before she left about picking her up in Phoenix. Daughter refused to pick mother up and became very angry that patient was discharging without her consent. Daughter feels mother is too ill to discharge. Daughter claimed to be Medical Power of Attorney (no record of that in client chart), and called the nursing station several times over the course of the evening demanding to know what bus the client was on and threatening to sue the facility if anything happened to her mother..."


I. Record review of Pt #1's Durable Mental Health Care Power of Attorney from the State of Arizona dated 05/03/19, revealed the following: "...Mental health treatment that I AUTHORIZE if I am unable to make decisions for myself: ...I authorize my mental health care representative to make on my behalf if I become incapable of making my own mental health care decisions due to mental or physical illness, injury, disability, or incapacity. If my wishes are not clear from this Durable Mental Health Care Power of Attorney or are not otherwise known to my representative, my representative will, in good faith, act in accordance with my best interests...

My representative is authorized to do the following which I have initialed or marked:

A. About my records: To receive information regarding mental health treatment that is proposed for me and to receive, review, and consent to disclosure of any of my medical records related to that treatment.

B. About medications: To consent to the administration of any medications recommended by my treating physician.

C. About a structured treatment setting: To admit me to a structured treatment setting with 24 hour-a-day supervision and an intensive treatment program licensed by the Department of Health Services, which is called an inpatient psychiatric facility..."


J. Record review of the facility's policy and procedure titled "Discharge Planning Process - After Care Plan," dated 07/2013, last revised 07/2018, revealed the following: "The development of a discharge plan begins on admission and continues throughout treatment as an interdisciplinary effort. Discharge criteria are established by the physician during the admission process and revised as necessary during the treatment...Early in the hospitalization it is important to identify patient who are likely to suffer adverse health consequences upon discharge if there is not adequate discharge planning. Barriers to discharge are identified in the psychosocial assessments and reassessed during treatment.

The patient's readiness for discharge should be linked to the achievement of treatment goals, although some for longer-term goals may be continued at another level of care following hospital discharge. Long-term goals represent the highest level of functioning which the patient is expected to achieve during this current episode of care...

The physician and therapist, with the support of nursing, coordinate the discharge arrangements with the patient and family. Certain dispositions/discharge needs may be considered for the patient, including a return to the home, placement in an Assisted Living or Skilled Nursing Facility, partial hospitalization, outpatient therapy, community programs and support groups, transportation, medical follow-up, and aftercare programs.

The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, or discharged to include: reason for transfer, referral or discharge, patient's physical and psychosocial status, summary of care provided and progress toward goals, and community resources and referrals provided to the patient...

The discharge/aftercare plan is a multidisciplinary form and defines the following:

1. Final diagnosis;

2. Where the patient will live following discharge based on patient/family needs and or wants;

3. The level of care which the patient will be discharged to (i.e., partial hospitalization, intensive outpatient, outpatient, etc.);

4. All professionals who will follow-up with the patient, including medical follow-up to monitor medications;

5. Specific efforts to educate the family/receiving facility/agency, regarding the patient's treatment interventions, nature and management of the patient's illness/disorder, medication and prognosis;

6. Includes a crisis management plan when indicated, which may include a mechanism to contact a physician, interim medication management, referral to or provision of a support group or individual supportive services, or a mechanism to contact an emergency services provider. Aftercare plans are communicated to the patient/family/legal representative or receiving facility/agency, as appropriate, and documented in the medical record. A copy of the aftercare/discharge form is given to the patient/family/legal representative or sent to the receiving facility/agency with the patient..."

Based on record review and interview, the facility failed to ensure that the discharge summary was complete and accurate including the Admission Diagnosis(es), the Reason for Discharge, and Follow Up for 1 (Patient #1) of 3 (Patient #'s 1 - 3) sampled patients, reviewed for completeness of medical records. This deficient practice of not completing the discharge summary, has the potential to impact the quality of care and efforts to connect patient's with community resources and continued care. The findings are:

A. Record review of the Discharge Summary dated 05/30/19, revealed the following:

1. No documentation regarding the patient's Admission Diagnosis(es);

2. No documentation regarding the patient's Reason for Discharge; and

3. No documentation regarding the patient's Follow Up.


B. Record review of the Discharge/Aftercare Instructions signed by Social Worker #1 dated 05/30/19, revealed the following:

1. No documentation regarding the patient's disposition, indicated under discharge location: friend's home, Phoenix, no address or phone number was indicated;

2. Discharge Diagnoses: under additional diagnoses, no documentation noted;

3. Under Social Services: Emergency/Crisis Planning & Risk Factors - name of therapist was not indicated;

4. Patient/legal representative verbalized understanding of information provided, Yes, No or N/A, no boxes were indicated.


C. On 12/05/19 at 11:15 am, during an interview, Social Worker [SW] #2, reviewed the Discharge/Aftercare Instructions for Patient #1. She stated, "I was taught not to leave any boxes blank. I was always told to fill out the entire instruction sheets. I don't see a Crisis Plan completed for this patient. The Crisis Plan indicates for the patient being discharged, as to what are their warning signs, triggers, or stressors; a list of names of people with their phone numbers who are their personal support system; a list of the patient's professional support system; a list of coping skills that the patient can use and had learned; phone numbers of community resources; and a Crisis Plan. The Crisis Plan indicates to the patient, if they need help I can..., then do the following that we have gone over with the patient. The Crisis Plan is a plan that the patient can go to if they do have a crisis after discharge. It is a follow-up for after discharge." SW #2 confirmed that SW #1 did not fill out the discharge/aftercare instructions for Pt #1 correctly.


D. Record review of the facility's policy and procedure titled "Documentation Protocol," dated 09/2008, last revised 11/2019, revealed the following:

"All medical records are to be accurate, truthful and complete. Staff are to document accurately services provided, patient interactions, and all financial records and transactions. Every staff who creates or reviews documentation in a medical record, or responds to or implements orders or directives contained in a medical record, ensures that the medical record complies with this Documentation Protocol. This duty to ensure accuracy of medical records applies to the entire medical record, not just documentation a staff individually creates, reviews or acts upon.

Purpose: To assure accurate and timely documentation; provide a means of communication between health care providers; provide a legal record to protect the patient, hospital and health care team; provide information in the medical record for performance improvement..."

Based on record review and interview, the facility failed to provide the patient's condition, anticipated problems after discharge, means and resources for interventions, and special problems related to the patient's functional ability to participate in aftercare planning on the discharge summary for 1 (Pt #1) of 3 (Pt #'s 1 - 3) patients, who were reviewed for discharge planning. This deficient practice led to the patient not having the proper resources for her care after discharge. The findings are:

A. Record review of Pt #1's medical chart the Discharge Summary dated 05/30/19, signed by Physician Assistant [PA] dated 05/31/19 and signed and dated by the Physician on 05/31/19, revealed no Admission Diagnosis, no Reason for Discharge, and no Follow Up instructions.

B. On 12/04/19 at 3:17 PM, during an interview, Social Worker [SW] #1, stated she was, "actively involved in finding her [Pt #1] doctor appointments. All of the interactions with her [Pt #1] are documented at the time they were discussed. I did not read the discharge summary signed by the doctor. The doctor was supposed to have a conversation with me. It's not my place to track down the doctor." When asked if she includes the patient in the discharge plan, she stated, "yes, absolutely." She also confirmed that she contacts the Power of Attorney [POA] and family members to be a part of the discharge planning process.

C. On 12/05/19 at 11:15 am, during an interview, SW #2, who has worked at the facility for over 2 years, stated that it would not matter to her, if the patient said, "Don't call my daughter [being the POA] or the physician invoking the POA. I would call the courts to determine if the Durable Mental Health Care POA was limited or had it expired. Pt #1's Durable Mental Health Care POA was in effect as of 05/03/19." She confirmed that SW #1's training should have been better. She stated that the training of SW's has been inconsistent since last November, which has affected the last two employees that we have hired, one being SW #1. She stated that if she was discharging a patient, who had no identification, she would make-up temporary identification. She also stated that she would have provided Pt #1 with a bag of groceries, that would have included a lunch sack from the facility, some granola bars and snacks, and bottled water. There have been times that we have filled their medication prescription. She stated that some of those bus rides are quite long, the bus ride from Albuquerque to Phoenix was an 8 hour and 55 minute average bus ride. SW #2 stated that when she first started working at the hospital, the SW was not given a case-load of patients until they were thoroughly trained. In regards to the Durable Mental Health Care POA, SW #2 stated that Pt #1 and her daughter [the POA] must have felt at the beginning of May, that this Durable Mental Health POA document should be put into place, or else Pt #1 would not have signed it. SW #2 stated, "The Durable Mental Health Care POA was a document to be considered, it is a legal document, which was notarized."

D. Record review of the facility's policy and procedure titled "Discharge Planning Process - After Care Plan," dated 07/2013, last revised 07/2018, revealed the following:

"The development of a discharge plan begins on admission and continues throughout treatment as an interdisciplinary effort. Discharge criteria are established by the physician during the admission process and revised as necessary during treatment...early in the hospitalization it is important to identify patients who are likely to suffer adverse health consequences upon discharge if there is not adequate discharge planning. Barriers to discharge are identified in the psychosocial assessments and reassessed during treatment.

The patient's readiness for discharge should be linked to the achievement of treatment goals, although some longer-term goals may be continued at another level of care following hospital discharge. Long-term goals represent the highest level of functioning which the patient is expected to achieve during this current episode of care...
The physician and therapist, with the support of nursing, coordinate the discharge arrangements with the patient and family. Certain dispositions/discharge needs may be considered for the patient, including a return to the home,...transportation, medical follow-up, and aftercare programs.

The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, or discharged to include: reason for transfer, referral or discharge, patient's physical and psychosocial status, summary of care provided and progress toward goals, and community resources and referrals provided to the patient..."

Based on interview and record review, the facility failed to ensure that the Director of Social Services oversees the operations of the Social Services department, by providing support, guidance, training, and information to the Social Services personnel. This deficient practice resulted in not preparing a Social Worker [SW] with guidance and support, during a discharge process for Patient #1, which was not a smooth transition from the hospital to the community. Patient #1 was tracked and found by family members to be in an emergency department of a hospital in Flagstaff, Arizona; she had not eaten, was dehydrated, and in a deep psychosis. The findings are:

A. On 12/04/19 at 3:17 pm, during an interview, Social Worker #1 [SW #1] who has been employed by the hospital since 03/25/19 and had previously worked at a local psychiatric facility for 2 years. SW #1 stated that as the discharge planner there was so much to learn, that there was a steep learning curve, she stated that she has learned by leaps and bounds. She stated that now, as opposed to the end of May, she has a different idea of what resources exist in New Mexico. SW #1 stated that during a telephone call that she had with Pt #1's daughter, SW #1 felt that the daughter was brow-beating her. She stated, "I got kinda stressed," I told the daughter, "I can't have this conversation with her, so I terminated the call." When asked if she hung-up on her, SW #1 replied, "I terminated the call."

SW #1 stated that she felt that the complaint investigation focus was being improperly put on her. She stated, "every day we have a treatment team meeting, we discuss the patient's insurance and what is happening with the patient." SW #1 stated that when Pt #1 first arrived at the facility, she was very demanding, she said she mellowed and her personality changed, she was able to participate in group therapy..."During the course of the week, I saw the change in her [being Pt #1]," said SW #1. SW #1 further stated, "as we went on, Pt #1 participated appropriately and was able to tell me what she wanted...she was afraid of her daughter [who was the POA (Power of Attorney)] and ex-husband, "They want to run my [Pt #1] life."

When asked if she had read the discharge summary from Pt #1's previous hospitalization, SW #1 replied, "No." When asked if she had talked with her supervisor regarding Pt #1's discharge, SW #1 stated, "As far as I know, I did go internally. No one told me that I did wrong. Now I'm paranoid and fearful. What could the ramifications be? I'm not gonna say it's my fault. There is literally nothing else I can tell you. I don't know if there's anything else I could have done. I'm not gonna talk about this with my manager because he has left. Now, I run to our temporary manager with everything. SW #1 stated, "I'm the one who goes overboard on everything. Even if it should be self-evident."

When asked if the patient is included in the discharge plan, SW #1 responded, "Yes, absolutely." When SW #1 was asked about the POA [Power of Attorney], she replied, "See, this is the part that's unclear to me. The patient tells me who I'm able to talk to." When asked if she contacts the POA to be part of the discharge, she said, "You're darn tootin'." When asked if her discussions with Pt #1 were documented, she said, "No, but it should be, I usually make a note on the PSA [Psycho-Social Assessment]." SW #1, when asked if she had documented any discussions with Pt #1, regarding her POA, said Pt #1 specifically said, "No, don't call my daughter." SW #1 stated, "I don't know if that is in my notes."

In regards to SW #1's training on discharge planning at the facility, she stated, "No. I never was trained. To be honest, I was kind of thrown into it. It takes a long time to get up to speed. You learn as you go. It was frustrating working with that supervisor [the previous supervisor, who no longer works in the facility]. She further stated, "We don't have time to track down the doctors, they're very busy. I honestly believed I was following self-determination. The POA was not invoked. At the time, I was doing as I thought was appropriate."


B. On 12/05/19 at 11:15 am, during an interview, SW #2, [another SW at the facility] who has worked at the facility for over 2 years, she stated that it would not matter to her, if the patient said, "Don't call my daughter [being the POA] or the physician invoking the POA. I would call the courts to determine if the Durable Mental Health Care POA was limited or had it expired. Pt #1's Durable Mental Health Care POA was in effect as of 05/03/19." She confirmed that SW #1's training should have been better. She stated that the training of SW's has been inconsistent since last November, which has affected the last two employees that we have hired, one being SW #1. She stated that if she was discharging a patient, who had no identification, she would make-up temporary identification. She also stated that she would have provided Pt #1 with a bag of groceries, that would have included a lunch sack from the facility, some granola bars and snacks, and bottled water. There have been times that we have filled their medication prescription. She stated that some of those bus rides are quite long, the bus ride from Albuquerque to Phoenix was an 8 hour and 55 minute average bus ride. SW #2 stated that when she first started working at the hospital, the SW was not given a case-load of patients until they were thoroughly trained. In regards to the Durable Mental Health Care POA, SW #2 stated that Pt #1 and her daughter [the POA] was something that they felt should be put into place in May, or else she would not have signed it. SW #2 stated, "The Durable Mental Health Care POA was a document to be considered, it is a legal document, which was notarized."


C. Record review of the Social Services Progress Note dated 05/14/19 [Pt #1 was not admitted to the hospital until 05/26/19. This was confirmed by the Chief Executive Officer (CEO), the date should have indicated 05/30/19], revealed the following: "[Name of Patient #1] wants to return to Phoenix and stay with a friend. Social worker purchased a bus ticket and made her doctor appointments in Phoenix. Right before patient left, it turned out she had lost her wallet and ID. However, she was able to get on the bus without it. She spoke to her daughter right before she left about picking her up in Phoenix. Daughter refused to pick mother up and became very angry that patient was discharging without her consent. Daughter feels mother is too ill to discharge. Daughter claimed to be Medical Power of Attorney (no record of that in client chart), and called the nursing station several times over the course of the evening demanding to know what bus client was on and threatening to sue the facility if anything happened to her mother..."


D. On 12/05/19 at 2:30 pm, the CEO confirmed that at this time, the facility does not have a Social Services Director, but one has been hired to work in the near future.


E. Record review of the facility's job description for the Social Services Director, undated, revealed the following: "Position Summary: Oversees the operations of the Social Services and Activity Therapy department, including assessment, program development/implementation and discharge planning; Actively participates in the Performance Improvement and Risk Management programs; Interprets accreditation and regulatory standards and implements processes to ensure compliance; Develops and implements goals, policies and protocols; and Provides patient care as outlined in the Social Service staff job description when necessary to fulfill the responsibilities of the department...Leadership: Serve as a member of the Management Team and on committees as assigned. Provide clinical and administrative leadership to social services staff by providing support, guidance, training and information..."

Based on record review and interviews, the facility failed to provide social services in accordance with accepted standards of practice for 1 (Patient #1) of 3 (Patient #'s 1 - 3) sampled patients reviewed for social service issues. This deficient practice, resulted in when Pt #1 was discharged from the hospital, she was not provided information as for her what to do when there were concerns, issues, or problems that arose during her bus trip from Albuquerque to Phoenix [the average bus trip was 8 hours and 55 minutes]. Patient #1 was in a emergency room in Flagstaff, when Pt #1's daughter, who was her mental health Power of Attorney (POA) and family tracked her down. Patient #1 did not arrive at her destination in Phoenix as planned. The findings are:

A. Record review of Pt #1's medical record revealed the following:
1. The Psychiatric Evaluation dated 05/26/19, indicated the following: "The patient is a 64-year-old female, who states that she was admitted from the [Name of local Healing Center] secondary to the doctor's concerns with regard to her mood and "mania." The patient states that she resides with her daughter and her daughter out of concern for the patient's safety...[was] admitted to [Name of local Healing Center]. Per the patient, this was to help keep her safe as well as to help with her overall mood and instability...She then further elaborates by stating that the facility staff became concerned when yesterday she "bought a condominium." She therefore was transferred again voluntarily to the facility for ongoing medication management and monitoring...patient has been hospitalized at least 5 times in the last 5 years for "what patient describes as emotional deprivation." She has also in the past attempted suicide on psychotropic medications while drinking alcohol. She has also been in a coma for 3 days with several of the patient's past hospitalizations being court ordered...The patient does have a power of attorney for her mental health and this is her daughter..."
2. The Admission History and Physical Examination dated 05/26/19, revealed the following diagnoses: "...history of Bipolar 2 [A type of bipolar disorder characterized by depressive (experiencing a deep sadness or hopelessness) and hypomanic (characterized by persistent disinhibition and mood elevation) episodes. It involves at least one depressive episode lasting at least two weeks and at least one hypomanic episode lasting at least four days], TBI [Traumatic Brain Injury, a brain dysfunction caused by an outside force, usually a violent blow to the head], HTN [hypertension, having high blood pressure], PTSD [Post Traumatic Stress Disorder, a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it] and seasonal allergies...She began to refuse her medications [while at the Healing Center] and started to become allegedly manic. Fighting with staff and residents. She was transferred to the facility for psychiatric management.
Past Medical History: PTSD, Bipolar 2, Manic, TBI, EDD [Emotional Deprivation Disorder, a deprivation of love during childhood development] and Delusions of grandeur [a false sense or unusual belief about one's greatness]..."
3. The Psychiatric Evaluation dated 05/14/19, revealed the following: "History of Present Illness: [Name of Pt #1] is a married 64-yo W F [64 year-old white female] with long history of depression recently diagnosed with Bipolar disorder, alcohol use disorder who presents a referred from [Name of Psychiatric Hospital in Arizona], as a step down. Patient was admitted for a manic episode (committed by her family)...She [Pt #1] reports that she has manipulated her way out of the psychiatric ward by not saying the truth to the doctors...She took an overdose on her psychotropic medications (Seroquel [an antipsychotic, it can treat bipolar disorder and depression], Surmontil [a nerve pain medication and antidepressant) along with drinking vodka, 'I did not want to die but it was a cry for help.'...Pt #1 reports that her family has not been able to handle her happiness 'they petitioned me for bipolar II turning into Bipolar I." Patient is in denial about the manic episodes and she thinks that the TBI has unlocked all her trauma from the past and she is flooded...She claims that she [sic] not manic but upset with her family; 'they forced me to take Seroquel 400 mg that night and I tore up my house."

B. On 07/18/19 at 9:56 am, during an interview, Pt #1's POA confirmed that she had been given the decision making authority for Pt #1 through a dated, signed and notarized Durable Mental Health Care Power of Attorney from the State of Arizona. She confirmed that she did not receive any communication (no letters, no phone calls, no emails, etc.) from Social Worker at the facility regarding Pt #1's care and impending discharge. The POA also stated that the hospital had discharged her mother with $6.00 in cash, no photo or other identification, when they tracked down her mother in Flagstaff in an emergency room, Pt #1 had not eaten, was dehydrated and in a deep psychosis.

C. Record review of the Social Services Progress Note dated 05/14/19 [the date was confirmed by Chief Executive Officer (CEO) that the note should have been dated 05/30/19], revealed the following: "[Name of Pt #1] wants to return to Phoenix and stay with a friend...Right before patient left, it turned out she had lost her wallet and ID. However, she was able to get on the bus without it. She spoke to her daughter right before she left about picking her up in Phoenix. Daughter refused to pick mother up and became very angry that patient was discharging without her consent. Daughter feels mother is too ill to discharge. Daughter claimed to be Medical Power of Attorney (no record of that in client chart), and called the nursing station several times over the course of the evening demanding to know what bus client was on and threatening to sue the facility if anything happened to her mother. Social worker called [Name of previous facility] to see if they had patient's wallet. Discharge: Patient is taking bus back to Phoenix and is calling a friend to pick her up."


D. On 12/04/19 at 3:17 PM, during an interview, Social Worker #1 [SW #1] who has been employed by the hospital since 03/25/19 and had previously worked at a local psychiatric facility for 2 years. SW #1 stated that as the discharge planner there was so much to learn, that there was a steep learning curve, she stated that she has learned by leaps and bounds. She stated that now, as opposed to the end of May, she has a different idea of what resources exist in New Mexico. SW #1 stated that during a telephone call that she had with Pt #1's daughter, SW #1 felt that the daughter was brow-beating her. She stated, "I got kinda stressed," I told the daughter, "I can't have this conversation with her, so I terminated the call." When asked if she hung-up on her, SW #1 replied, "I terminated the call." SW #1 stated that she felt that the complaint investigation focus was being improperly put on her. She stated, "every day we have a treatment team meeting, we discuss the patient's insurance and what is happening with the patient." SW #1 stated that when Pt #1 first arrived at the facility, she was very demanding, she said she mellowed and her personality changed, she was able to participate in group therapy..."During the course of the week, I saw the change in her [being Pt #1]," said SW #1. SW #1 further stated, "as we went on, Pt #1 participated appropriately and was able to tell me what she wanted...she was afraid of her daughter [who was the POA] and ex-husband, "They want to run my [Pt #1] life." When asked if she had read the discharge summary from Pt #1's previous hospitalization, SW #1 replied, "No." When asked if she had talked with her supervisor regarding Pt #1's discharge, SW #1 stated, "As far as I know, I did go internally. No one told me that I did wrong. Now I'm paranoid and fearful. What could the ramifications be? I'm not gonna say it's my fault. There is literally nothing else I can tell you. I don't know if there's anything else I could have done. I'm not gonna talk about this with my manager because he has left. Now, I run to our temporary manager with everything. SW #1 stated, "I'm the one who goes overboard on everything. Even if it should be self-evident." When asked if the patient is included in the discharge plan, SW #1 responded, "Yes, absolutely." What about the POA [Power of Attorney]? SW #1 stated, "See, this is the part that's unclear to me. The patient tells me who I'm able to talk to." When asked if she contacts the POA to be part of the discharge, she said, "You're darn tootin'." When asked if her discussions with Pt #1 were documented, she said, "No, but it should be, I usually make a note on the PSA [Psycho-Social Assessment]." SW #1, when asked if she had documented any discussions with Pt #1, regarding her POA, said Pt #1 specifically said, "No, don't call my daughter." SW #1 stated, I don't know if that is in my notes."

In regards to SW #1's training on discharge planning at the facility, she stated, "No. I never was trained. To be honest, I was kind of thrown into it. It takes a long time to get up to speed. You learn as you go. It was frustrating working with that supervisor [the previous supervisor, who no longer works in the facility]. She further stated, "We don't have time to track down the doctors, they're very busy. I honestly believed I was following self-determination. The POA was not invoked. At the time, I was doing as I thought was appropriate."

E. On 12/05/19 at 11:15 am, during an interview, SW #2, [another SW at the facility] who has worked at the facility for over 2 years, she stated that it would not matter to her, if the patient said, "Don't call my daughter [being the POA] or the physician invoking the POA. I would call the courts to determine if the Durable Mental Health Care POA was limited or had it expired. Pt #1's Durable Mental Health Care POA was in effect as of 05/03/19." She confirmed that SW #1's training should have been better. She stated that the training of SW's has been inconsistent since last November, which has affected the last two employees that we have hired, one being SW #1. She stated that if she was discharging a patient, who had no identification, she would make-up temporary identification. She also stated that she would have provided Pt #1 with a bag of groceries, that would have included a lunch sack from the facility, some granola bars and snacks, and bottled water. There have been times that we have filled their medication prescription. She stated that some of those bus rides are quite long, the bus ride from Albuquerque to Phoenix was an 8 hour and 55 minute average bus ride. SW #2 stated that when she first started working at the hospital, the SW was not given a case-load of patients until they were thoroughly trained. In regards to the Durable Mental Health Care POA, SW #2 stated that Pt #1 and her daughter [the POA] was something that they felt should be put into place in May, or else she would not have signed it. SW #2 stated, "The Durable Mental Health Care POA was a document to be considered, it is a legal document, which is notarized."

F. On 12/05/19 at 2:30 PM, the CEO confirmed that at this time, the facility does not have a Social Services Director, but one has been hired to work in the near future.


G. Record review of "Social Work Best Practice Healthcare Case Management Standards," from the National Association of Social Workers: NASW Standards for Social Work Case Management. Washington DC, NASW, June 1992, revealed the following: "...Definition: Social Work Case Management is a method of providing services whereby a professional Social Worker collaboratively assesses the needs of the client and the client's family, when appropriate, and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client's complex needs...The Social Worker works collaboratively with other professionals to maintain a team-oriented approach to Case Management. This approach also incorporates the patient and family in care decision making...Reassessment is an ongoing process, with a formal reassessment conducted a prescribed intervals and whenever there is a significant change in the patient's health, abilities, living situation, family involvement, etc. Reassessment should include evaluation of the type and intensity of case management services required, with changes made to the treatment plan accordingly. Intervention Methods/Options: Development of Social Work Case Management Treatment Plan-Once several options have been developed, the Social Work Case Manager helps patients and family member/significant others review advantages and disadvantages to each option. Together, the Social Work Case Manager, patient, and family/significant others formulate an individualized effective case management treatment plan and implementation strategies. The plan will identify the patient's strengths and support systems and utilize them in implementation strategies..."