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Based on interview and document review, the facility failed to provide a copy of Important Message from Medicare about their rights within 2 days of admission to 1 of 1 Medicare patients (P1) reviewed.


Findings include:


Review of P1's face sheet identified P1 was admitted 11/2/15, and was discharged 11/6/15. The face sheet further identified P1's primary healthcare coverage was Medicare.


Review of P1's important message from Medicare about your rights was signed and dated 11/5/15.


On 1/6/16, at 3:30 p.m. during record review, health information management staff (HIMS-A) confirmed P1 was admitted to the hospital on 11/2/15, and Medicare was identified as P1's primary healthcare coverage. The HIMS-A verified P1 had not received the Important Message (IM) regarding her Medicare rights until 11/5/15, three days after admission. He confirmed P1's IM had not been completed within the required 2 days of admission.


On 1/7/16, at 12:27 p.m. during interview with registered nurse (RN)-A, RN-F and RN-A stated the resource nurse was responsible for providing the IMs to assist patients to understand their Medicare rights. RN-F stated once a patient was admitted, their patient access department determined the patient's healthcare coverage. RN-F also stated if a patient was identified as a Medicare recipient, the patient access department would either call them or send an IM directly to the nursing unit's printer and once they found the IM on the printer, they had the patient sign and date the document. Then a copy was faxed to patient access and the original was placed in the patient's paper chart on the unit. RN-F reported she was unaware of the time constraints for completing the IMs for patients. She stated she was familiar with the case but wasn't sure why the IM was not completed on time. RN-A confirmed P1's admission date of 11/2/15, the IM had not been completed until 11/5/15, but should have been completed by 11/4/15. RN-A stated usually they got the IMs completed immediately, but was unsure of the circumstances as to why this IM wasn't.


Review of the hospital policy Message from Medicare, Procedure for Obtaining Signature dated 8/12/15, indicated the message from Medicare was an informational letter to Medicare beneficiaries regarding Medicare rights. The Omnibus Budget Reconciliation Act of 1996, requires that all hospitals provide Medicare beneficiaries the informational letter within 2 days of admission.

Based on interview and document review, the hospital failed to ensure 2 of 11 providers (MD-B, NP-A) had been appropriately credentialed. This had the potential to affect all patients admitted to the hospital.

Findings include:

On 1/5/16, at 3:23 p.m. patient experience director (PED), who oversaw the credentialing process for the hospital, confirmed nurse practitioner (NP)-A had not applied for, nor had been recommended by the medical staff, or approved by the governing board for privileges to practice at Sanford Behavioral Health Center (SBHC). The PED confirmed NP-A was currently scheduled to work at SBHC.

On 1/5/16, at 3:40 p.m. the PED confirmed medical doctor (MD)-B had not indicated the setting (Sanford Clinic, Sanford Medical Center, and/or SBHC) for which he had requested privileges on MD-B's 9/8/15, application for clinical privileges form.

On 1/6/16, at 11:04 a.m. the chief executive officer (CEO) and chief medical officer (CMO) confirmed SBHC had a unified medical staff since they opened on 9/29/15. The CEO and CMO stated it would be their expectation that the credentialing process be followed as directed by the medical staff bylaws regarding the providers need to identify the setting/location for which there privileges were being requested.

On 1/6/16, at 2:00 p.m. the chief operating officer (COO) stated NP-A had initially intended to not practice at SBHC, then NP-A changed her mind and decided to work at SBHC on a casual basis. Unfortunately, PED had not received this information, so the credentialing process had not been initiated. Both COO and PED confirmed NP-A should have completed the request for privileges and followed the credentialing process for appointment at SBHC. The COO stated SBHC was in the process of providing NP-A with temporary privileges. The COO confirmed NP-A had been scheduled and provided care and treatment to patients at SBHC since they opened 9/29/15.

On 1/6/16, at 2:10 p.m. the PED verified MD-B had not delineated on his 9/8/15, request for privileges application of the setting/location of where he had requested what privileges.

On 1/7/16, at 8:24 a.m. the director of nursing (DON) confirmed when NP-A was scheduled at the hospital, this included providing sole 24 hour medical coverage for the hospital which included rounding on patients, admitting patients and the provider who staff would call for emergencies.

On 1/7/16, at 9:30 a.m. the clinical director of operations (CDO) verified she organized the provider schedule for the hospital. The CDO confirmed NP-A had been scheduled and worked the following 24 hour shifts at SBHC: 10/17/15, 10/18/15, 10/30/15, 10/31/15, 11/1/15, 11/26/15, 11/27/15, 11/28/15, 11/29/15, 12/11/15, 12/12/15, and 12/13/15. The CDO stated when there was a change in privileges and/or a new provider approved for privileges, PED verbally notified the CDO of this information. The CDO confirmed this verbal exchange of privilege information was the only notification process.

MD-B's 9/8/15, application for clinical privileges lacked identification of which setting/location MD-B had requested privileges.

Credentialing policy: Sanford Medical Center Thief River Falls & Sanford Behavioral Health Center dated 9/3/15, indicated basic qualifications for application for practitioners must agree to abide by the Bylaws, Rules and Regulations. In addition, every applicant for medical staff appointment and reappointment must contain a request for the specific privileges within the practitioner's areas of practice and the setting where the practitioner had requested to exercise those privileges.

The Sanford Medical Center Thief River Falls and Sanford Behavioral Health Center Medical/Professional Staff Bylaws dated 10/29/15, indicated at the time of completing a request for medical/professional staff applicant, the applicant should indicate in which service(s) and which setting(s) he/she wishes privileges

Based on interview and document review, the hospital failed to include the pharmacist in the notification, investigation and follow-up for 4 of 5 patient (P2, P17, P18, P19) medication errors reported. In addition, the hospital failed to incorporate medication error review into the hospital-wide quality program.

Findings include:

On 1/5/16, at 2:15 p.m. the pharmacist confirmed she had not received notification of any medication error reports which had been initiated at the hospital since they had opened on 9/29/15. The pharmacist stated she should have received information of every medication error right away because if there was a medication error with a potential for harm to a patient she would have wanted to take care of this and would have followed-up on the error right away. The pharmacist confirmed she had not been able to do her part in investigation and follow-up as she hadn't received notification of the medication errors. In addition, the pharmacist confirmed because she had not received the medication error reports and medication error review had not been incorporated into the hospital-wide quality program.

On 1/5/16, at 2:56 p.m. the quality director (QD) verified the pharmacist had not received the medication error reports which had been initiated at the hospital since it had opened on 9/29/15, and she should have. The QD confirmed the medication errors on P2, P17, P18, P19 fit the hospital's definition of a medication error.

On 1/7/16, at 9:15 a.m. the QD verified the number of medication errors were being collected as far as data collection, however, medication error review was not incorporated into the hospital-wide quality program.

On 1/6/16, at 8:15 a.m. licensed practical nurse (LPN)-A stated with any medication error she would initiate a variance in the computer, notify the registered nurse and the physician and make a notation in the patient's medical record of the error. Registered nurse (RN)-C agreed with LPN-A's response and attempted unsuccessfully to pull up the policy on the computer.

- On 11/4/15, a medication error report initiated on P2. The date of the medication error (event) was listed as 10/16/15. The 11/4/15, documentation on the medication error report indicated an order had been obtained on 10/15/15, to increase P2's bedtime Melatonin (medication which helps regulate sleep and wake cycles) to 10.5 milligrams (mg), however, P2's mother had refused to approve this medication increase. On 12/3/15, the notation from RN-E indicated the medication error needed to be reviewed. Notation on the medication error report dated 12/7/15, indicated RN-B had reviewed P2's chart and followed up with the registered nurse who had received the denial for consent for the medication increase. However, the medication error report lacked pharmacy's acknowledgement of this error and/or any participation in investigation and/or follow-up.

On 1/6/15, at 9:43 a.m. RN-A confirmed P2's medical record lacked documentation of the 10/16/15, medication error.

- On 11/15/15, a medication error report was initiated on P17. The date of the event was listed as 11/15/15. The 11/5/15, documentation on the medication error report indicated Saphris (antipsychotic medication) had been ordered and started on 11/11/15, and the medication had been given without the proper written consent. On 11/16/15, RN-E noted the error. On 11/17/15, the notation from RN-A indicated this would be addressed with process flow education to staff and audit updates. However, the medication error report lacked pharmacy's acknowledgement of this error and/or any participation in investigation and/or follow-up.

On 1/6/16, at 3:18 p.m. RN-B confirmed R17's medical record lacked documentation of the 11/15/15, medication error.

- On 11/25/15, a medication error report was initiated on P18. The date of the event was listed as 11/25/15. The 11/25/15, documentation on the medication error report indicated P18 had been admitted on 11/24/15, at 5:00 p.m. and the provider had been notified to check medications and orders. The order was never placed to restart P18's home medications and P18 had not received her home medications until 11/25/15, at 11:00 a.m. On 12/3/15, the notation from RN-E indicated a reminder and policy review had been sent out as a coaching tool. The medication error report lacked detailed information of what medications P18 had missed or were delayed. In addition, the medication error report lacked pharmacy's acknowledgement of this error and/or any participation in investigation and/or follow-up.

On 1/6/16, at 3:40 p.m. RN-B confirmed P18's medical record lacked documentation of the 11/25/15, medication error.

- On 12/8/15, a medication error report was initiated on P19. The date of the event was listed as 12/7/15. The 12/8/15, documentation on the medication error report indicated P19's home medication which consisted of Zyprexa (antipsychotic) and trazodone (antidepressant) had been sent home with a different patient. On 12/9/15, RN-B noted the error. On 12/11/15, RN-E noted an on-going review was being conducted in partnership with the privacy office in Fargo. On 12/29/15, RN-B indicated a data breach had been filed with the Sanford privacy office in Fargo. R19's medications had been received back from the incorrect patient. Medication bottles included Zyprexa, trazadone, Celexa (antidepressant), Depakote (mood stabilizer) and Nexium (acid reflux medication). P19 had been given new prescriptions. In addition, the medication error report indicated P19' s medication bag had been mislabeled with the incorrect patient sticker. Education had been provided to staff to verify names on all medication bottles prior to returning them to the patient. However, the medication error report lacked pharmacy's acknowledgement of this error and/or any participation in investigation and/or follow-up.

On 1/6/16, at 3:53 p.m. RN-B confirmed R19's medical record lacked documentation of the 12/7/15, medication error and it should have been documented.

Medication Administration and Variance Policy dated 11/6/15, indicated pharmacy would be included in the review of medication error data as part of the hospital's continuous improvement process.

The Master Service Agreement dated 9/28/15, between Sanford Behavioral Health Center and Sanford Medical Center Thief River Falls indicated pharmacy services would be provided which included review of medication errors and participation into the facility's quality assurance program to monitor, evaluate, and improved ongoing patient quality care

Based on interview and document review, the facility failed to accurately identify nutritional risk and comprehensively assess 1 of 1 patients (P1) reviewed for nutrition.


Findings include:


P1's History and Physical (H&P)s dated 9/30/15, and 10/21/15, both identified P1 had a history of Prader-Willi syndrome (a rare disease caused by missing or non-working genes affecting multiple parts of the body, including excessive eating and obesity). However, the registered dietician (RD) failed to identify this nutritional risk diagnosis.


On 1/7/15, at 10:20 a.m. RD-B stated she screened and assessed all hospital patients for nutrition risk. She stated after she screened each patient, she assigned them a nutrition risk level (low, moderate or high). She stated she determined nutritional risk using both the patient's medical record, including their H&P for medical history and diagnoses, along with their nutrition risk screening criteria document. RD-B stated on 9/29/15, she had screened P1 and assessed her to be a low nutritional risk. However, RD-B stated she had not completely read P1's H&P therefore she had not identified P1 had Prader Willi syndrome until P1's third hospital admission on 10/20/15. During the 10/20/15, hospitalization RD-B confirmed she did not assess P1 until 10/30/15, and assessed P1 at only a moderate nutrition risk level because P1 was eating well and nursing was already watching her food intake. RD-B stated she wasn't sure of how P1's eating was monitored outside of the common area, or if P1 was monitored for eating any non-food items. RD-B stated she was unsure if P1 had ever eaten or had access to non-food items. RD-B verified she missed the Prader Willi diagnoses and should have assessed P1 at high nutrition risk. RD-B stated she had never seen P1 face to face to complete an assessment or provide P1 with any education and she should have. RD-B stated she reported to a registered nurse (RN) patient care manager, but RD-C oversaw her clinical work as RD-C better understood the nutrition process versus a nurse.


On 1/7/15, at 11:30 a.m. RD-C stated P1 should have been assessed at high nutrition risk according to P1's medical record, including her H&P along with their nutrition risk screening criteria. She stated she felt P1 was definitely at high nutrition risk because it would be really hard to have stable nutrition with Prader Willi syndrome. She also stated because RD-B missed P1's Prader Willi syndrome diagnoses, P1 wasn't assessed correctly. She confirmed there had never been a nutrition consult ordered for P1 by any medical staff. She also stated P1 should have been seen face to face for assessment.


Review of P1's nutrition progress notes revealed the following:

-9/30/15, P1 screened at low nutritional risk.
-10/7/15, P1 screened at low nutritional risk
-10/21/15, P1 screened at low nutritional risk. Due to Prader Willi syndrome P1's intake should be closely monitored as P1 may not be able to control her own food intake and may try to eat non-food items.
-10/30/15, P1 was moderate nutrition risk. P1 had been on a regular diet before this admission and was to follow a 1500 calorie restricted diet. P1 had a good appetite and nursing did not report any complaints regarding the diet. Meal plans were provided.


Review of the clinical dietitian's job description, undated identified the scope of practice for a registered dietitian included optimization of nutritional status by providing medical nutrition therapy to patients with high nutrition risk. This includes determination of nutritional status through nutritional assessment, individualized care plans, provider order, nutrition therapy, education and counseling for disease and nutrition risk management, and evaluation of outcomes of medical nutrition therapy interventions.


Review of the Dietitian Assessment & Reassessment policy dated 8/12/15, identified it was the responsibility of the dietitian to screen and assess patients for nutritional risk. The associated Inpatient Nutrition Risk Screening Criteria document identified Inborn Errors of Metabolism to be a Level I/High Nutrition Risk.

Based on interview and document review, the hospital failed to have an agreement/contract with an eye procurement organization. This had the potential to affect all patients admitted to the hospital.

Findings include:

On 1/5/16, at 1:08 p.m. registered nurse (RN)-A stated she was unable to find an agreement/contract with an eye procurement organization.

On 1/5/16, at 1:54 p.m. the quality director confirmed the Sanford Behavioral Health Center did not have a current agreement or contract with an eye procurement organization.

Sanford Behavioral Health Center (SBHC) Contract list lacked identification of an eye procurement organization.

Organ and Tissue Donation policy dated 8/27/15, outlined the process for referral of potential tissue and/or eye donation. The policy identified the Minnesota Lions Eye Bank as their eye procurement organization. However, the hospital lacked an agreement with this eye procurement organization.

Organ and Tissue Recovery Agreement with Lifesource (an organ and tissue procurement organization) directed the hospital to refer all potential eye donors to the respective eye recovery agencies designated by the hospital.

Based on interview and record review, the facility failed to:

I. Provide psychiatric evaluations (identified by this facility as Psychiatry History and Physical) that include an assessment of intellectual functioning and of memory functioning in measurable, behavioral terms for six (6) of six (6) active sample patients (1, 2, 3, 4, 5, and 6). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

II. Provide psychiatric evaluations that include an assessment of patient's assets in descriptive non-interpretive form for six (6) of six (6) sample patients (1, 2, 3, 4, 5, and 6). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy. (Refer to B117)

III. Develop and document master treatment plans for six (6) of six (6) sample active patients (1, 2, 3, 4, 5, and 6) to include behaviorally stated outcome goals, interventions based on the patients' individual needs treatment team members responsible for patient care. This failure resulted in absence of master treatment plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

Based on record review and staff interviews, the facility failed to ensure that the social service assessments included conclusion and recommendations for social work services from data gathered for six (6) of six (6) active sample patients (1, 2, 3, 4, 5, and 6). As a result of these deficiencies specific summary and recommendations regarding treatment of the patients' psychosocial problems were not described for the treatment team. Deficiencies further created the potential to delay treatment, prolong hospital stay and prevent patients from having the available community resources needed to aide them in the recovery process.

Findings include:

A. Record review

1. Patient 1
The psychosocial assessment dated 12/31/15 failed to include social work conclusions and recommendations.

2. Patient 2
The psychosocial assessment dated 1/1/16 failed to include conclusions and recommendations.

3. Patient 3
The psychosocial assessment dated 12/31/15 failed to include conclusions and recommendations

4. Patient 4
The psychosocial dated 1/3/16 failed to include conclusion and recommendations.

5. Patient 5
The psychosocial dated 1/4/2016 failed to include conclusions and recommendations.

6. Patient 6
The psychosocial dated 12/29/15 failed to include conclusions and recommendations.

B. Interview

During interview on 1/5/16 at 3:10 p.m., the Director of Social Work acknowledged that the psychosocial assessments did not include a summary and recommendations for treatment by social work.

Based on medical record review and staff interview the facility failed to provide psychiatric evaluations ( identified by this facility as Psychiatry History and Physical) that include tests performed to assess intellectual and memory functioning behavioral to establish diagnosis and baseline objective for future comparisons for six (6) of six (6) active sample patients (1, 2, 3, 4, 5, and 6). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include

A. Record review

1. Patient 1
The psychiatric evaluation dated 12/31/2015 failed to document tests performed to assess memory in a descriptive manner to establish diagnosis and an objective baseline for future comparisons. The only statement was "Recent and remote memory intact." Intellectual functioning was not addressed.

2. Patient 2
The psychiatric evaluation dated 1/2/2016 failed to document tests performed to assess memory in a descriptive manner to establish diagnosis and an objective baseline for future comparisons. The only statement was "Recent and remote memory intact." Intellectual functioning was not addressed.


3. Patient 3
The psychiatric evaluation dated 12/31/15 failed to document tests performed to assess memory in a descriptive manner to establish diagnosis and an objective baseline for future comparisons. The only statement was "Recent and remote memory intact." Intellectual functioning was not addressed.

4. Patient 4
The psychiatric evaluation dated 1/4/16 failed to document tests performed to assess memory in a descriptive manner to establish diagnosis and an objective baseline for future comparisons. The only statement was "Recent and remote memory intact." Intellectual functioning was not addressed.

5. Patient 5
The psychiatric evaluation dated 1/4/2016 failed to document tests performed to assess memory in a descriptive manner to establish diagnosis and an objective baseline for future comparisons. The only statement was "Recent and remote memory intact." Intellectual functioning was not addressed.


6. Patient 6
The psychiatric evaluation dated 12/29/15 failed to document tests performed to assess memory in a descriptive manner to establish diagnosis and an objective baseline for future comparisons. The only statement was "Recent and remote memory intact." Intellectual functioning was not addressed.


B. Interview

During interview on 1/5/16 at 2:00 p.m., the Medical Director acknowledged that intellectual functioning was not addressed and that memory testing was not described.

Based on record review and interview the facility failed to provide psychiatric evaluations that include an assessment of patient's assets in descriptive non-interpretive form for six (6) of six (6) sample patients (1, 2, 3, 4, 5, and 6). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy.

Findings include:

A. Record review

1. Patient 1
Psychiatric evaluation dated 12/31/2015 failed to include a list of the patient's assets.

2. Patient 2
Psychiatric evaluation dated 1/2/2016 failed to include a list of the patient's assets.

3. Patient 3
The psychiatric evaluation dated 12/31/15 failed to include a list of the patient's assets.

4. Patient 4
The psychiatric evaluation dated 1/4/16 failed to include a list of the patient's assets.

5. Patient 5
Psychiatric evaluation dated 1/4/2016 failed to include a list of the patient's assets.

6. Patient 6
The psychiatric evaluation dated 12/29/15 failed to include a list of the patient's assets.

B. Interview

During interview on 1/5/16 at 2:00 p.m., the Medical Director acknowledged that patient assets were not listed in the psychiatric evaluations.

Based on interview and record review, the facility failed to develop and document master treatment plans based on the individual needs of six (6) of six (6) sample active patients (1, 2, 3, 4, 5 and 6). This failure resulted in absence of master treatment plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings.

Findings include:

A. Review of the treatment plans for 6 of 6 sample patients (6 of 6 sample active patients (1-dated 1/4/16; 2-dated 1/4/16; 3-dated 1/4/16; 4-dated 1/4/16; 5-dated 1/4/16; and 6-dated 1/4/16) revealed that the master treatment plans were based on a computerized program. The program provided sections for patient diagnosis and identified problem; these sections were the only portions of the plans completed in the patients' plans. Patient treatment goals were not present in all master treatment plans. In the treatment plans where goals were listed, all goals were non-measurable. The only other content in the treatment plans was a list of medications that the patient was being given during hospitalization; the list failed to include focus of medication nor were any of the listed medications correlated with treatment of the stated patient problem. There were no sections identified in the treatment format for interventions and identification of staff responsible for interventions, thus, there were no staff interventions or responsible staff identified in the master treatment plans for all six (6) active sample patients.

B. Interviews:

1. During interview on 1/5/16 at 2:00 p.m., the Medical Director acknowledged that the lists of medications in the patient treatment plans were not correlated with the identified patient problem.


2. During interview on 1/5/16 at 3:10 p.m., the Director of Social Work stated, "The patient should be involved in the treatment plan (referring to development of the plan)."

3. During interview on 1/5/16 at 2:00 p.m., the DON stated, "These (plans) do not have any interventions."

4. During interview, with review of treatment plan findings; on 1/5/16 at 3:30 p.m., the DON stated, "The goals were non-measureable." RN 1 stated, "The goals are subjective. There are no clear interventions (in the treatment plans) by anybody (disciplines). Interventions must be present (in the treatment plans) and assigned to a staff member."

Based on record review and interview, the Clinical Director failed to:

I. Provide psychiatric evaluations (identified by this facility as Psychiatry History and Physical) that include assessment of intellectual and memory functioning in measurable, behavioral terms for six (6) of six (6) active sample patients (1, 2, 3, 4, 5, and 6). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

II. Provide psychiatric evaluations that include an assessment of patient's assets in descriptive non-interpretive form for six (6) of six (6) sample patients (1, 2, 3, 4, 5, and 6). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy. (Refer to B117)


III. Develop and document master treatment plans for six (6) of six (6) sample active patients (1, 2, 3, 4, 5, and 6) to include behaviorally stated outcome goals, interventions based on the patients' individual needs treatment team members responsible for patient care. This failure resulted in absence of master treatment plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

Based on observation, interview and document review, the Director of Nursing failed to ensure that nursing interventions were included in treatment plans based on the individual needs of six (6) of six (6) sample active patients (1-dated 1/4/16; 2-dated 1/4/16; 3-dated 1/4/16; 4-dated 1/4/16; 5-dated 1/4/16; and 6-dated 1/4/16). Nursing interventions were absent in all master treatment plans. This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

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

1. Based on record review and staff interviews, the facility failed to ensure that the social service assessments included conclusion and recommendations for social work services from data gathered for six (6) of six (6) active sample patients (1, 2, 3, 4, 5, and 6). As a result of these deficiencies specific summary and recommendations regarding treatment of the patients' psychosocial problems were not described for the treatment team. Deficiencies further created the potential to delay treatment, prolong hospital stay and prevent patients from having the available community resources needed to aide them in the recovery process. (Refer to B108)

II. Provide treatment plans that identified social work interventions that were specific to the treatment needs for six (6) of six (6) active sample patients (1, 2, 3, 4, 5 and 6). This failure results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment, and potentially delaying patient improvement, and discharge from the hospital. (Refer to B118)

III. Provide monitoring to ensure psychosocial assessments completed by Registered Nurses include social work conclusion and recommendation for six (6) of six (6) active sample patients (1, 2, 3, 4, 5, and 6). As a result of these deficiencies specific summary and recommendations regarding treatment of the patients' psychosocial problems were not described for the treatment team and the patients potentially not having all knowledge of community resources available to aid in their recovery.

Findings include:

A. Record review

1. Patient 1
The document entitled "Psychosocial History/Assessment" for active sample patient 1 (dated 12/31/2015) was completed by a Registered Nurse (RN); there was no indication that there was oversite provided from a social worker. The assessment did not include Social service conclusion and recommendation. The treatment Plan dated 1/4/16 did not include intervention for social work.

2. Patient 2
The document entitled "Psychosocial History/Assessment" for active sample patient 1 (dated 1/1/16) was completed by a Registered Nurse (RN); there was no indication that there was oversite provided from a social worker. The assessment did not include Social service conclusion and recommendation. The treatment Plan dated 1/4/16 did not include intervention for social work.

3. Patient 3
The document entitled "Psychosocial History/Assessment" for active sample patient 1 (dated 12/30/15) was completed by a Registered Nurse (RN); there was no indication that there was oversite provided from a social worker. The assessment did not include Social service conclusion and recommendation. The treatment Plan dated 1/4/16 did not include intervention for social work.



4. Patient 4
The document entitled "Psychosocial History/Assessment" for active sample patient 1 (dated 1/3/16) was completed by a Registered Nurse (RN); there was no indication that there was oversite provided from a social worker. The assessment did not include Social service conclusion and recommendation. The treatment Plan dated 1/4/16 did not include intervention for social work.

5. Patient 5
The document entitled "Psychosocial History/Assessment" for active (dated 1/4/16) was completed by a Registered Nurse (RN); there was no indication that there was oversite provided from a social worker. The assessment did not include Social service conclusion and recommendation. The treatment Plan dated 1/4/16 did not include intervention for social work.
.
6. Patient 6
The document entitled "Psychosocial History/Assessment" for active sample patient 1 (dated 12/29/15) was completed by a Registered Nurse (RN); there was no indication that there was oversite provided from a social worker. The assessment did not include Social service conclusion and recommendation. The treatment Plan dated 1/4/16 did not include intervention for social work.

B. Interview

During interview on 1/5/16 at 3:10 p.m., the Director of Social Work stated that she is present when the nurse presents his/her findings documented in the psychosocial assessment in the treatment team meetings. She stated that currently there is no proof of oversight review.