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Based on medical record review and staff interview, the facility failed to ensure that the Psychosocial Assessments for 11 of 13 sample patients (A1, A2, A3, A4, A6, A7, A8, A9, A10, A11 and A13 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 deficiency results in the treatment team not having the necessary information to develop effective and meaningful treatment plans.

Findings include:

A. Record Review

1. Patient A1 was admitted on a voluntary basis to Dayhoff-Unit A on 1/20/11 due to psychosis with fixed delusions of persecution and depression. The entire Discharge Plan section of the Psychosocial Assessment completed by the social worker on 1/24/11 consisted of: "Return to the Home Run."

2. Patient A2 was admitted to Adolescent Dayhoff - Unit B on 2/24/11 for a court ordered evaluation due to assaultive behavior and substance abuse, runaway behaviors and mood problems. The complete Discharge Plan section of the Psychosocial Assessment completed by the social worker on 2/24/11 stated "Pt. [patient] will return to court upon completion of evaluation."

3. Patient A3 was admitted to the Dayhoff- Unit C on 2/24/11 for a court ordered competency evaluation due to substance abuse and delusions of grandiosity related to his religious beliefs. The Discharge Plan section of the Psychosocial Assessment completed by the social worker on 2/25/11 consisted of the single statement: "Return to family."

4. Patient A4 was admitted to Noyes Unit on 7/12/09 after violating her conditional release. The Discharge Plan section of the Psychosocial Assessment completed by the social worker on 7/14/09 had the one statement: "Patient needs outpatient mental health treatment and supervised housing."

5. Patient A6 was admitted to Smith Building on 10/13/10 with a history of paranoid delusions and homicidal ideation. The entire Discharge Plan section of the Psychosocial Assessment completed by the social worker on 10/18/10 stated "There are no current discharge plans at this time, until medically stable/psychiatrically."

6. Patient A7 was admitted to White Unit B on 2/9/11 with a history of paranoid delusions and assaultive behavior. The Discharge Plan section of the Psychosocial Assessment completed by the social worker on 2/26/11 consisted of the single statement: "Patient would like to go to supervised housing."

7. Patient A8 was admitted to White Unit C on 3/11/10 with a history of assaultive behavior resulting in court adjudication of "guilty but not criminally responsible." The Discharge Plan section of the Psychosocial Assessment completed by the social worker on 3/15/10 stated only: "Patient will need a conditional release plan to reflect a stable living arrangement. He will need a court order for release and a FRB [Forensic Review Board] approval for level increases."

8. Patient A9 was admitted to White Unit D on 1/4/11 with a history of delusions, assaultive behavior, and hallucinations. The Discharge Plan section of the Psychosocial Assessment completed by the social worker on 1/5/11 stated only: "Patient conditional release plan (NCR status) will most likely be revoked, and he will need a new after care plan and ALJ [Administrative Law Judge] release hearing to be discharged back to the community."

9. Patient A10 was admitted to RB1 with a history of sexual abuse, borderline IQ and self injurious behavior. The Discharge Plan section of the Psychosocial Assessment completed by the social worker on 4/1/09 consisted of only: "Supervised housing with case management outpatient mental health care, psychotherapy, GED/vocational training."

10. Patient A11 was admitted to RB2 on 8/9/10 with a history of unlawful possession with intent to distribute heroin. The entire Discharge Plan section of the Psychosocial Assessment completed by the social worker on 8/11/10 stated "Patient will need supportive housing. Patient will need benefits."

11. Patient A13 was admitted to RB4 on 3/31/09 with a history of unpredictable manic and psychotic behavior. The entire Discharge Plan section of the Psychosocial Assessment completed by the social worker on 10/8/09 stated "Patient will need to be restored to competency and then will receive a responsibility evaluation. Patient would benefit from structured, supervised housing with daily medication management given her history of non compliance."

B. Staff Interviews

1. The surveyor met with SW1 regarding Patient A1 at 9:45am on 3/9/11 in reference to the Discharge Plan of the Psychosocial Assessment. SW1 confirmed that the discharge planning information for this patient was not adequately documented.

2. The surveyor met with SW2 regarding Patient A2 at 10:30am on 3/9/11 in reference to the Discharge Plan of the Psychosocial Assessment. SW2 confirmed that the discharge planning information for this patient was not adequately documented.

3. The surveyor met with the Director of Social Work at on 3/9/11 at 1:30pm to discuss the 11 of 13 sample Patient Psychosocial Assessments. The Director confirmed that the Discharge Plan of the Psychosocial Assessment did not provide clear recommendations for discharge planning.

Based on record review and interview, the Director of Social Services failed to monitor the development of the Psychosocial Assessment Discharge Plan to ensure that each included the evaluation of high risk psychosocial issues requiring early treatment planning and intervention and the social worker's conclusions and recommendations for social work intervention during hospitalization. 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:

In a review of the Psychosocial Assessments, for 11 of 13 sample patients (A1, A2, A3, A4, A6, A7, A8, A9, A10, A11 and A13), the assessments were found to be incomplete and failed to include: 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. For details of each patient's record, please refer to B108.

B. Staff Interview:

During the interview with the Director of Social Services at 1:30pm on 3/9/11 she acknowledged the deficiencies.. Since she had not previously considered that the findings outlined in detail in B108 were deficient, she acknowledged that her monitoring and evaluation process failed to appropriately monitor the Psychosocial Assessment Discharge Plans completed by her staff.