HospitalInspections.org

Bringing transparency to federal inspections

1001 STERIGERE STREET

NORRISTOWN, PA 19401

PROGRESS NOTES RECORDED BY SOCIAL WORKER

Tag No.: B0128

Based on record review, policy review and interview, the hospital failed to assure that social workers wrote monthly progress notes that that specifically addressed patient progress towards treatment goals and discharge planning. Eight of 15 sample patients (A2, A5, A6, A8, A9, A10, A11 and A14) had similar or identical monthly notes; four of 15 sample patients (A6, A8, A10 and A11) had missing monthly notes. Additionally, one sample patient (A6) had a missing Transfer note. Lack of social work documentation of patient progress and transfers impedes the treatment team's ability to evaluate the patient's response to treatment.

Findings include:

A. Record Review

1. Patient A2:

The patient was admitted 8/7/03 with a diagnosis of Schizoaffective, Bipolar type). The Social Work Monthly Note for 7/7/10 was identical to the Social work Monthly Note of 6/10/10. Both notes were written by the same family social worker. Patient A2's Social Work Monthly Note for 9/30/10, signed by SW3, is identical to the note of 9/2/10 signed by SW2, with the exception of the following sentence: "Discussion focuses on identifying and practicing coping skills [patient] can use when feeling agitated. [Patient] is making limited progress on this objective, requiring many prompts to attempt it. [Patient] attended her treatment plan review meeting and listened to a review of her objectives on 9/29/10."

2. Patient A5

The patient was admitted on 6/29/89, diagnosed with Schizophrenia Chronic Undifferentiated [type]. When the patient's record was reviewed on 10/18/10, the Social Work Monthly Note for 8/31/10 was similar to Social work Monthly Note for 9/23/10. Both notes were written by the same SW8.

a. [8/31/10]: "Social Work Monthly Note: Family Education" "This social worker has sent [patient's] family an invitation to treatment team but they did not attend nor did they respond to the letter.[Patient] is presently in the resource identification Phase of discharge planning. When ready for discharge, [patient] will need court permission to start discharge process. The team will recommend a LTSR placement due to elopement history. This social worker will assist [patient] in obtaining case management. This social worker will also assist [patient] in applying for medical and ssi benefits." Signed by SW8

b. [9/23/10]: "Social Work Monthly Note: Family Education" "This social worker has sent [patient's] family an invitation to treatment team but they did not attend nor did they respond to the letter. [Patient's] sister has been able to come to the hospital to visit where she spoke to this social worker about progress. [Patient] is presently in the resource identification Phase of discharge planning. When ready for discharge, [patient] will need court permission to start discharge process. The team will recommend a LTSR placement due to elopement history. This social worker will assist [patient] in obtaining case management. This social worker will also assist [patient] in applying for medical and ssi benefits." Signed by SW8

3. Patient A6

The patient was admitted on 4/17/06 with diagnoses of Factitious Disorder and Borderline Personality Disorder. The patient currently resides on Civil Psychiatry 10A1 (as a transfer in September 2010). When the patient's record was reviewed on 10/19/10, there was no Transfer Social Work Note for the month of September 2010 and no Social Work Monthly Note for October 2010.

4. Patient A8

The patient was admitted on 3/2/10 with a diagnosis of Bi-Polar Mood Disorder with Psychotic Features and Poly-substance Dependence. The patient currently resides on Forensics Unit 51A1. When the patient's record was reviewed on 10/19/10, there were no Social Work Monthly Notes for May 2010 or August 2010.

5. Patient A9

The patient was admitted on 10/11/05 with a diagnosis Paranoid Schizophrenia. The patient currently resides on the Civil Psychiatry Unit 01A1. When the patient's record was reviewed on 10/19/10, the Social Work Monthly Note sections in the section entitled Discharge/Family were general and had few variations from the Social Work Monthly Notes of 1/28/10, 3/1/10, 3/22/10, 4/22/10, 5/25/10, 6/22/10, 7/22/10, 8/30/10 and 9/30/10.

a. [1/28/10]: "Social Work on Service/Monthly Note: Discharge/Family involvement" "Mr. [Patient] is in the Assessment Phase of discharge planning. Currently, Mr. [patient] believes he is ready for discharge but continues to refuse to visit any LTSR which is the only housing option the Bucks county judge will agree to. SW meets with county liaison, TM, on a quarterly basis to discuss progress and discharge options. He [patient] has been found NGRI [not guilty by reason of insanity] for the homicide of his mother and any discharge plan must be approved by the court. [Patient] receives SSD in the amount of $1200/month and has Medicare A & D. ID is on file at NSH. [Patient's] family has no contact with him. His family has requested to be contacted in the event of discharge OR AWOL and this can be done via the police or DA. Social Worker will educate Mr. [patient] regarding community resources, benefit eligibility and Bucks County placement options." Signed by SW2

b. [3/1/10]: "Social Work on Service/Monthly Note: Discharge/Family involvement" This note was identical to the note cited in (a) above.

c. [4/22/10]: "Social Work on Service/Monthly Note: Discharge/Family involvement" This note is identical to the note cited in (a) above.

d. [5/25/10]: "Social Work on Service/Monthly Note: Discharge/Family involvement" This note is identical to the note cited in (a) above with the following two exceptions: [added]: "Recently his lawyer has become unable to practice and he is in the process of having a new lawyer assigned" and [deleted]: "SW meets with county liaison, TM, on a quarterly basis to discuss progress and discharge options."

e. [6/22/10]: "Social Work on Service/Monthly Note: Discharge/Family involvement" This note is identical to the note cited in (d) above.

f. [7/22/10]: "Social Work on Service/Monthly Note: Discharge/Family involvement" This note was identical to the note cited in (d) above.

g. [8/30/10]: "Social Work on Service/Monthly Note: Discharge/Family Involvement" was identical to the note cited in (d) above except that was signed by SW3 (a different Social Worker).

h. [9/30/10]: "Social Work on Service/Monthly Note: Discharge/Family Involvement" This note was similar to the note cited in (d) above except that the following two phrases were added and several sentences were deleted: "Mr. [AH] is in the Assessment Phase of discharge planning. Currently, Mr. [AH] believes he is ready for discharge but continues to refuse to visit any places. [AH]'s has no family contact. Mr. [AH] will be educated by the social worker regarding community resources, benefit eligibility and Bucks County placement options when he feels ready." The note was signed by SW4.

6. Patient A10

The patient was admitted on 7/23/03 with a diagnosis Chronic Paranoid Schizophrenia. The patient currently resides on Psychiatry Unit 01C1. When the patient's record was reviewed on 10/18/10, the Social Work Monthly Note regarding discharge was general and repetitive for the notes on 5/3/10, 6/10/10, 6/30/10, 7/21/10, and 9/1/10. The Social Work Monthly Note for August was missing.

a. [5/03/10]: "Social Work Monthly Note" "[Patient] is in the Assessment Phase of discharge. He had a CSP scheduled, but due to a miscommunication with staff, it had to be canceled and we are currently waiting to hear [sic] when it will be rescheduled. When ready for discharge, he will benefit from maximum care CRR with a forensic component. It would be beneficial for him to continue with Double Trouble or another 12 step meeting once residing in the community in addition to daily day programming in an attempt to assist with restructuring his day. Social Worker will assist in applying for benefits. [Patient] remains in contact with his Aunt [name] with whom he speaks with via telephone and occasional day passes. She does not attend treatment team meetings. He also remains in contact in touch with his cousins and [named person] occasionally sends some spending money. Education: Social Worker will educate [patient] and his family on local services and supports that will be available within the area he is discharged." Signed by SW5

b. [6/10/10: "Social Work Monthly Note" This note was identical to the note cited in (a) above.

c. [6/30/10]: "Social Work on Service/Monthly Note" The note was identical to the note (a) cited above with the exception of the following added sentence: "He had a CSP meeting which went relatively well, but stated that he plans to return to selling drugs, which he hadn't mentioned before the meeting."

d. [7/21/10]: "Social Work on Service/Monthly Note" This note was identical to the note cited above with the exception of the following deleted sentence: "He had a CSP meeting which went relatively well, but stated that he plans to return to selling drugs, which he hadn't mentioned before the meeting."

e. [August 2010]: The Social Work on Service/Monthly Note was missing.

f. [9/1/10]: "Social Work on Service/Monthly Note" This note was identical to note (d) cited above.

7. Patient A11

The patient was admitted on 5/19/10 with a diagnosis Chronic Paranoid Schizophrenia. The patient currently resides on Psychiatry Unit 01A1. When the patient's record was reviewed on 10/18/10, the Social Work Monthly Notes regarding discharge were general and repetitive. The Social Work Monthly Notes for 8/05/10 and 9/15/10 were identical. The Social Work Monthly Notes for June and July were missing.

a. [June 2010]: The Social Work Monthly Note was missing.

b. [July 2010]: The Social Work Monthly Note was missing.

c. [8/05/10]: "Social Work Monthly Note" "[Patient] remains in the Assessment Phase of discharge. When ready for discharge, she will require a residential facility with 24 hour staff support, likely a personal care home, so that they may provide hands on care to complete ADLs and to ambulate safely. [Patient] enjoys listening to Dolly Parton music and reading poetry; [Patient] has two poems published, but has not written in sometime. [Patient] receives SSD around $1000 monthly for which her sister is her payee. [Patient] has granted permission for this writer to contact her sister, [name], and she has been involved in two treatment team meetings. (M) calls the ward daily to check on [patient] and staff speak with her at length regarding (AS's) progress. SW also remains in contact with [name] and invites her to all the team meetings. Social Worker will educate both the patient and her sister in local community resources that will be available on discharge."

d. [9/15/10]: "Social Work Monthly Note" This note was identical to the note cited above.

8. Patient A14

The patient was admitted on 10/12/89 with a diagnosis of Delusional Disorder NOS. The patient currently resides on Forensics Unit P-1. When the patient's record was reviewed on 10/19/10, the Social Work Monthly Note for 9/30/10 was identical to Social Work Monthly Note for 9/2/10, except for one sentence.

a. [9/2/10]: "Social Work on Service/Monthly Note" "Social Work is working with [patient] on P-1, history of impulsive behaviors, threats towards peers and assaults. Social Work will be addressing O2: communicate thoughts/feelings with staff or peers in a clear manner for one minute once per week. [Patient] will be seen in weekly casework sessions, 1:1, to provide individual supportive counseling and address any concerns he may have related to his frustration with peers. [Patient] is a Montgomery County resident and is followed by NSH/Montgomery County MH/MR Liaison [name initials]. [Patient] receives money on a monthly basis from his brother, [name]. [Patient's] family contact is with his brother, [name]. [Name] visits several times a year and tends to his hospital care and maintenance bills. He is reachable by telephone, but does not contact this worker or facility very often." Signed by FSW1

b. [9/30/10]: "Social Work Monthly Note" "This note was identical to the note in (a) above except for the following additional sentence: "[Patient] has not made any statements related to his going up or being sad."] Signed by FSW1

B. Policy Review

The Social Work Policy on Progress Notes dated September 2002 and approved review on September 9, 2008 states in Policy #4, "Monthly Treatment Note" states "These notes are to be written every 30 days and must identify objectives of treatment plan, and the patient's progress towards meeting these objectives."

C. Staff Interview

1. In an interview, on 10/18/10 at 2:00PM, the CSRE (Chief of Social Work/Rehab Executive) and the Social Work Supervisor (SWS2) confirmed that there were none or few changes in the Social Work Monthly notes and that the notes did not reflect the work that social workers were doing for sample patients A9, A10 and A11.

2. In an interview on 10/19/10 at 9:30 AM with SWS#1 [Social Work Supervisor] regarding Patient A8, the surveyor asked the Supervisor to show where Social Work Monthly Notes are in the record. She responded "I don't see anything for May and August 2010; I've only been acting supervisor since early September 2010." SWS#1 acknowledged that the hospital policy says social worker notes are to be completed every 30 days.

3. In an interview, on 10/19/10 at 9:45 AM, the Medical Director confirmed that there were no or few changes in the Social Work Monthly notes. The Medical Director also acknowledged that the August Social Work note was missing in patient A10's medical record and the June and July notes were missing in patient A11's medical record.
.
4. In an interview, on 10/19/10 at 10:30AM, SW2 confirmed that there were no or few changes in the Social Work Monthly notes. SW2 also acknowledged that the August note was missing in patient A10's medical record and that the June and July notes were missing in patient A11's medical record.

5. In an interview on 10/19/10 at 11:30AM, SW# 2 and the Director of Social Work both confirmed that the September 2010 Transfer/In Note for Patient A6 was not in the record. SW#2 responded "I guess I did not get to her on my chart list.' The Director of Social Work said "This was an error and did not follow policy."

6. In an interview on 10/20/10 at 11:30AM with the Chief Social Rehabilitation Executive (CSRE) and the Director of Social Work (DSW), the CSRE stated "We need more room for improvement and perhaps we should look at whether we need to have Assessment phase on Social Work Notes." The DSW stated "We need to be more specific and individualized and provide better social work supervision for our workers on their records."

SOCIAL SERVICES

Tag No.: B0152

Based on record review and interview, the Director of Social Services failed to assure that Social Work Progress Notes met professional social work standards for 8 of 15 sample patients (A2, A5, A6, A8, A9, A10, A11 and A14). Specifically, the Social Work Director failed to assure the quality and appropriateness of social services progress notes. This failure can result in a lack of professional social work treatment services and hampers the treatment team's ability to identify address important treatment issues and discharge planning needs. (Refer to B128)