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Based on the record review and staff interview, the facility failed to ensure that the Psychosocial Assessments for 8 of 8 sample patients (BH1, BH2, BH3, BH4, NPI1, NPI2, NPI3, NPI4) were complete and included: 1) an evaluation of high risk psychosocial issues requiring early treatment planning and intervention; 2) recommendations concerning anticipated necessary steps to be taken for discharge to occur; and 3) anticipated Social Work roles in treatment and discharge planning. This failure to document recommendations in the Psychosocial Assessments results in an inadequate data base for patients' psychosocial needs and compromises the effective development and formulation of quality treatment plans, potentially resulting in negative impact to quality of patient care.

Findings include:

A. Record Review

1. Patient BH1 was admitted to the Behavioral Health Unit 5/26/11 for treatment of depression with a suicide attempt. The Discharge Plan section of the Psychosocial Assessment completed by the social worker on 5/27/11 checked the boxes for "outpatient therapy" and "psychiatric follow-up" with a notation in both for "referral." The summary section of the Psychosocial Assessment did not identify issues requiring early treatment planning and intervention, anticipated necessary steps to be taken for discharge, to occur or the anticipated Social Work roles in treatment and discharge planning.

2. Patient BH2 was admitted to Behavioral Health Unit on 6/9/11 for treatment of depression, anxiety and alcohol abuse. The summary section of the Psychosocial Assessment dated 6/10/11 did not identify issues requiring early treatment planning and intervention, anticipated necessary steps to be taken for discharge to occur, or the anticipated Social Work roles in treatment and discharge planning.

3. Patient BH3 was admitted to the Behavioral Health Unit 6/6/11 for treatment of an "Eating Disorder" and a "Mood Disorder." The summary section of the Psychosocial Assessment dated 6/7/11 did not identify issues requiring early treatment planning and intervention, anticipated necessary steps to be taken for discharge to occur, or the anticipated Social Work roles in treatment and discharge planning.

4. Patient BH4 was admitted to the Behavioral Health Unit 6/8/11 for treatment of depression, anxiety and suicidal ideation. The summary section of the Psychosocial Assessment dated 6/9/11 did not identify issues requiring early treatment planning and intervention, anticipated necessary steps to be taken for discharge to occur, or the anticipated Social Work roles in treatment and discharge planning.

5. Patient NPI1 was admitted to the Neuropsychiatric Unit 4/23/11 for treatment of deficits associated with his traumatic brain injury and schizophrenia. The summary section of the Psychosocial Assessment dated 4/26/11 did not identify issues requiring early treatment planning and intervention, anticipated necessary steps to be taken for discharge to occur, or the anticipated Social Work roles in treatment and discharge planning.

6. Patient NPI2 was admitted to the Neuropsychiatric Unit 5/5/08 for treatment of psychosis and aggression associated with her traumatic brain injury and depression. The summary section of the psychosocial Readmission Assessment Update dated 5/27/10 did not identify issues requiring early treatment planning and intervention, anticipated necessary steps to be taken for discharge to occur, or the anticipated Social Work roles in treatment and discharge planning.

7. Patient NPI3 was admitted to the Neuropsychiatric Unit 4/20/11 for treatment of psychosis and aggression associated with his traumatic brain injury and depression. The summary section of the psychosocial Readmission Assessment Update, undated, did not identify issues requiring early treatment planning and intervention, anticipated necessary steps to be taken for discharge to occur, or the anticipated Social Work roles in treatment and discharge planning.

8. Patient NP43 was admitted to the Neuropsychiatric Unit 10/8/2009 for treatment of psychosis and impulse dyscontrol associated with traumatic brain injury and depression. The summary section of the psychosocial Readmission Assessment Update dated 10/9/09 did not identify issues requiring early treatment planning and intervention, anticipated necessary steps to be taken for discharge to occur, or the anticipated Social Work roles in treatment and discharge planning.

B. Staff Interview

The surveyor met with the Director of Social Work at on 6/14/11 at 2:45pm to discuss the Psychosocial Assessments. The Director confirmed that the Psychosocial Assessments did not adequately demonstrate anticipated necessary steps for discharge to occur; high risk psychosocial issues requiring early treatment planning and immediate intervention; specific community resources/support systems for utilization in discharge planning; or the anticipated social work role(s) in treatment and discharge planning.

Based on record review and interview, the Director of Social Services failed to ensure that the section of the Psychosocial Assessment related to conclusions and recommendations contained anticipated necessary steps for discharge to occur; high risk psychosocial issues requiring early treatment planning and immediate intervention; specific community resources/support systems for utilization in discharge planning; or the anticipated social work role(s) in treatment and discharge planning. These failures can result in a lack of professional social work discharge planning, as the treatment team may fail to identify important discharge planning needs.

Findings:

A. Record Review:

The Psychosocial Assessments for 8 of 8 sample patients (BH1, BH2, BH3, BH4, NPI1, NPI2, NPI3, NPI4) were incomplete, no containing the areas noted above. Refer to B108 for the individual record findings.

B. Staff Interview:

During the interview with the Director of Social Services at 2:45pm on 6/14/11 he acknowledged that he had not monitored the assessments completed by his staff in the areas related to recommendations for treatment by social work staff during hospitalization, and for discharge planning.