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Based on record review and staff interviews, the facility failed to ensure that the social service assessments included individualized recommendations for social work services from the data gathered for 5 of 8 active sample patients (A14, A24, B7, C7, and C13). As a result, social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams.

Findings include:

A. Record Review

1. Patient A14 was admitted on 7/29/13. The psychosocial assessment, done on 7/30/13, did not include individualized social service recommendations. The documented recommendations were generalized statements and not based on identified psychosocial problems. They were: "pt. (patient) will need confirmed DC (discharge) placement and f/u (follow up) services with IHS (Indian Health Services)."

2. Patient A24 was admitted on 6/26/13. The psychosocial assessment, done on 6/27/13, did not include individualized recommendations. The documented recommendations were generalized statements and not based on identified psychosocial problems. They were: "pt. (patient) will continue to f/u w (with) CODAC (acronym of an agency) and need more secure housing placement."

3. Patient B7 was admitted on 7/31/13. The psychosocial assessment, done on 8/1/13, did not include individualized recommendations. The documented recommendations were generalized statements and not based on identified psychosocial problems. They were: "name of patient] would benefit from a CDIOP (Chemical Dependency Intensive Outpatient Program) and primary care follow up apt.[sic] (appointment)."

4. Patient C7 was admitted on 7/24/13. The psychosocial assessment, done on 7/26/13, did not include individualized recommendations. The documented recommendation was generalized statement and not based on identified psychosocial problems. It was: "Safe D/C (discharge) plan in place" and were identical to social service recommendations of patient C13.

5. Patient C13 was admitted on 7/24/13. The psychosocial assessment, done on 7/24/13, did not include individualized recommendations. The documented recommendation was generalized statement and not based on identified psychosocial problems. It was: "Safe D/C plan in place" and were identical to social service recommendations of patient C7.

B. Staff Interview

During an interview on 8/6/13 at 3:25 p.m., the Director of Social Work stated, "Absolutely, I agree with you these recommendations are generic and they could be improved and individualized."

Based on record review and staff interview, it was determined that the facility failed to document an estimate of memory functioning with supportive information in the psychiatric evaluation for 3 of 8 active sample patients (A8, B12 and D2). This failure potentially results in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromises future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

A. Record Review

Patient A8 was admitted on 7/39/13. The psychiatric evaluation, done on 7/31/13 stated, "Memory Functioning - within normal limits per interview." There was no supportive information documented. The documented information was generic in nature and was identical to the same information documented for sample patients B12 (psychiatric evaluation done 7/31/13), and D2 (psychiatric evaluation done 7/31/13).

B. Staff Interviews

1. During an interview on 8/6/13 at 8:45 a.m., The Medical Director stated, "I know my docs (Doctors) are asking different questions to check memory and orientation but I understand where you are coming from. I agree it is not reflected in their documentation. I agree it looks generic."

2. During an interview on 8/6/13 at 11:15 a.m., with the CEO (Chief Executive Officer) and the Director of Quality Improvement, the Director of Quality Improvement stated, "I agree with your findings (referring to memory findings). We still have some improvement to provide."

Based on record review and interviews, the facility failed to identify the name and/or discipline responsible for each specific intervention on the Master Treatment Plan (MTP) for 3 of 8 active sample patients (B7, B12, and D2). These practices results in the facility's inability to clearly monitor staff responsibility for seeing specific interventions are carried out.

Findings include:

A. Record Review

1. Facility policy, #PC-001, titled "Treatment Planning", dated 9/5/12, stated: "The Treatment Plan should contain specific interventions....and...include person responsible for implementation." The revised Treatment Plan policy, dated 8/1/13, stated that the interventions should include: "Responsible Staff:-The name[s] and credentials/discipline of the specific staff members responsible for the provision of the intervention."

2. Patient B7
The Master Treatment plan, dated 8/1/13, listed the following staff interventions associated with the problem "potential for alteration in comfort/ safety- Physiological symptoms ETOH detox (alcohol detox). N+V (nausea and vomiting), triggers, dizziness":

"Practitioner will order/evaluate detox management for detox protocol." No name was listed as the responsible staff. The "discipline" column on the form said "psychiatrist".
"Staff will provide medication education in groups and 1-1 (one to one)." No name was cited for responsible staff. The discipline was "RN."
"SS (social services) will assist with making appt. w OP (appointment with outpatient) follow-up." No name was listed.
"Staff will provide sobriety/coping skills, education daily via group/ind (individual) or written handouts." No name listed as responsible staff(s). The discipline listed was "all staff."

3. Patient B12
The MTP, dated 8/5/13, listed the following staff intervention associated with "suicidal ideation/homicidal ideation as evidenced by verbalized thoughts/depression" as follows:

"Directed [sic] journaling related to [his/her] loss of spirituality." "[Name of patient] will verbalize in group SI (suicidal ideation) triggers." The same first initial and last name of the responsible person was listed for each intervention, but there was no discipline included.
There was no physician's signature or intervention on the treatment plan, so the physician's name was not included.

4. Patient D2
The MTP, dated8/2/13, listed the following staff intervention associated with the problem "Aggressive Behavior":

"Provide structured activities to increase impulse control by: helping pt. (patient) participate in groups to a (illegible) peer-leisure skills, social skills." The discipline of the person was "BHT (Behavior Health Technician)." No specific name was mentioned.

B. Interview

In an interview on 8/6/13 at 8:45 a.m., the problem of lack of names and disciplines documented on the treatment plans as the responsible person to be held accountable for making sure an individual intervention was being carried out was discussed with the Medical Director. He was shown the MTP, dated 8/1/13, of active sample patient B7. The Medical Director stated, "I don't see names of the disciplines on this treatment plan."

Based on record review and staff interview, it was determined that the facility failed to ensure that the discharge summaries for 5 of 5 sampled discharged patients (E1, E2, E3, E4, and E5) contained a summary of the patient's condition on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology and risk were not available to the aftercare providers.

Findings include:

A. Record Review

1. Patient E1 was discharged on 6/28/13. In the Discharge summary dictated on 6/28/13, the condition on discharge was documented only as "improved from admission."

2. Patient E2 was discharged on 7/2/13. In the Discharge summary dictated on 7/3/13, the condition on discharge was documented only as "improved."

3. Patient E3 was discharged on 6/27/13. In the Discharge summary dictated on 6/27/13, the condition on discharge was documented only as "improved."

4. Patient E4 was discharged on 6/29/13. In the Discharge summary dictated on 7/1/13, the condition on discharge was documented only as "stable."

5. Patient E5 was discharged on 6/24/13. In the Discharge summary dictated on 6/24/13, the condition on discharge was documented only as "patient is ready for discharge."

B. Staff Interview:

During an interview on 8/6/13 at 08:45 AM, Medical Director stated, "We are improving but it (improvement) is not 100% yet. It is a work in progress."

Based on record review and interviews, it was determined that the Director of Social Services failed to monitor and evaluate the quality and appropriateness of social services provided to patients at the facility. Specifically the Director of Social Services failed to assure that Social service assessments included individualized recommendations for social work services from the data gathered for 5 of 8 active sample patients (A8, A14, A24, B7, C7, and C13). As a result, social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams. (Refer to B108 for record findings.)

B.Staff Interview:

During an interview on 8/6/13 at 3:25 p.m., the Director of Social Work stated, "Absolutely, I agree with you these recommendations are generic and they could be improved and individualized."

Based on record review and interview, the facility failed to provide a MSW- prepared Director of Social Work, or to assign one of MSW- level staff currently employed at the facility to fulfill the duties, functions and responsibilities of the Director of Social Work. As a result, there was no professionally designed and directed social work program for 8 of 8 sample patients (A8, A14, A24, B7, B12, C7, C13, and D2 ), as well as the facility's entire patient population.

Record Review:

1. The review of resume of the Director of Social Work indicated that the Director of Social Work was not MSW qualified.

2. The job description of A & R Evaluator (Assessment and Referral), who is a MSW and a Licensed Clinical Social Worker, provided by the Director of Human Resources on 8/5/13, did not specifically include the responsibilities to also provide clinical supervision to all inpatient social workers because the Director of Social Services did not hold a Master's degree in social work.

Staff Interviews:

1. During an interview on 8/5/13 at 10:25 a.m., SW1 stated, "I report to the Director of Social Services. She is responsible for my day to day work as a social worker. I see the A & R director weekly for my clinical supervision hours because I am working on my licensure and I need supervisory hours."

2. During an interview on 8/5/13 at 11:55 a.m., the Director of Social Services stated, "I do not have a MSW. My degree is a PhD in clinical psychology. I supervise all social workers for their day to day social work functions and responsibilities. We do have a MSW staff (referring to A & R Evaluator) in our intake area that provides weekly clinical supervision to unlicensed social workers and counselors."

3. During an interview on 8/5/13 at 12:55 p.m., the Director of Human Resources stated, "She (referring to A & R Evaluator) provides clinical supervision to therapists and social workers who are not licensed."

4. During an interview on 8/6/13 at 10:30 a.m., A & R Evaluator stated, "I work full time in our intake department. I provide weekly clinical supervision only to unlicensed counselor and social workers. Some of the social workers also need clinical supervisory hours for their licensure exam. The Director of Social Work is responsible for the day to day supervision of all inpatient social workers." When asked whether she also provided clinical supervision to licensed inpatient social workers A & R Evaluator stated, "Technically no, they (referring to licensed counselors and licensed social workers) do not need my supervision and I do not supervise them. The Director of Social Services provides day to day supervision to all inpatient social work."

5. During an interview on 8/6/13 at 8:45 AM on the qualifications of the Director of Social Services, the Medical Director stated, "I see she has a PhD in Psychology. Maybe it works from the management and clinical oversight perspective but it does not meet the Medicare standard."