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900 EAST MAIN STREET

NORMAN, OK 73070

SOCIAL SERVICES RECORDS PROVIDE ASSESSMENT OF HOME PLANS

Tag No.: B0108

Based on interviews and record reviews, the hospital failed to provide Psychosocial Assessments which had been reviewed and signed in a timely fashion for 8 of 8 active sample patients (Patients A1, A2, B1, B2, C1, C2, E1, E2.) Failure to have social work staff review and sign their reports leaves treatment teams to work with assessments whose information has not been verified.

Findings include:

A. Record Reviews:

Patient A1 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/5. At the time of the survey on 6/13/11 the report was unsigned.

Patient A2 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/3. At the time of the survey on 6/13/11 the report was unsigned by the supervising MSW.

Patient B1 was admitted 5/30. The Psychosocial Assessment was transcribed on 6/3. At the time of the survey on 6/13/11, the report was noted to have been signed on 6/1/2011, which was prior to transcription.

Patient B2 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/6. The report was noted to have been signed on 6/13/11.

Patient C1 was admitted 5/26. The Psychosocial Assessment was transcribed on 6/5. At the time of the survey on 6/13/11 the report was unsigned.

Patient C2 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/5. At the time of the survey on 6/13/11 the report was unsigned.

Patient E1 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/3. At the time of the survey on 6/13/11 the report was unsigned.

Patient E2 was admitted 5/26. The Psychosocial Assessment was transcribed on 5/28. The report was noted to have been signed on 6/13/11.

B. Interviews:

1) In an interview on 6/14/11 at 9:45a.m., the Director of Social Work acknowledged that the Psychosocial Assessments of the 8 active sample patients, (A1, A2, B1, B2, C1, C2, E1, E2) were either unsigned or were not signed in a timely fashion. The Director acknowledged that this meant the assessments had not been reviewed or corrected by Social Work Department staff. The Director stated that the failure to review and sign assessments was not acceptable. The Director also stated that the staff member who signed Patient B1's report frequently recorded erroneous dates.

2) In an interview with the Medical Director on 6/14/11 at 9:00am, the Medical Director acknowledged that the Psychosocial Assessments of the 8 active sample patients, (A1, A2, B1, B2, C1, C2, E1, E2) were either unsigned or were not signed in a timely fashion. The Medical Director stated that the Social Work Department lacked a system to monitor staff reviews and signatures of assessments.

3) In an interview with the hospital CEO on 6/14/11 at 4:30pm, the CEO acknowledged that that the Psychosocial Assessments of the 8 active sample patients, (A1, A2, B1, B2, C1, C2, E1, E2) were either unsigned or were not signed in a timely fashion.

SOCIAL SERVICES

Tag No.: B0152

Based on interviews and record reviews, the Director of Social Work failed to provide Psychosocial Histories which had been reviewed and signed in a timely fashion for 8 of 8 active sample patients (Patients A1, A2, B1, B2, C1, C2, E1, E2). Failure to have social work staff review and sign their reports leaves treatment teams to work with assessments whose information has not been verified.

Findings:

A) Record Reviews:

Patient A1 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/5. At the time of the survey on 6/13/11 the report was unsigned.

Patient A2 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/3. At the time of the survey on 6/13/11 the report was unsigned by the supervising MSW.

Patient B1 was admitted 5/30. The Psychosocial Assessment was transcribed on 6/3. At the time of the survey on 6/13/11, the report was noted to have been signed on 6/1/2011, which was prior to transcription.

Patient B2 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/6. The report was noted to have been signed on 6/13/11.

Patient C1 was admitted 5/26. The Psychosocial Assessment was transcribed on 6/5. At the time of the survey on 6/13/11 the report was unsigned.

Patient C2 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/5. At the time of the survey on 6/13/11 the report was unsigned.

Patient E1 was admitted 5/31. The Psychosocial Assessment was transcribed on 6/3. At the time of the survey on 6/13/11 the report was unsigned.

Patient E2 was admitted 5/26. The Psychosocial Assessment was transcribed on 5/28. The report was noted to have been signed on 6/13/11.

B. Interviews:

1) In an interview on 6/14/11 at 9:45am with the Director acknowledged that the Psychosocial Assessments of the 8 active sample patients (A1, A2, B1, B2, C1, C2, E1, E2) were either unsigned or were not signed in a timely fashion. The Director acknowledged that this meant the assessments had not been reviewed or corrected by Social Work Department staff. The Director stated that the staff member who signed the report for patient B1 frequently recorded erroneous dates. The Director stated that the failure to review and sign assessments was not acceptable.

2) In an interview with the Medical Director on 6/14/11 at 9:00am, the Medical Director acknowledged that the Psychosocial Assessments of the 8 active sample patients, (A1, A2, B1, B2, C1, C2, E1, E2) were either unsigned or were not signed in a timely fashion. The Medical Director stated that the Social Work Department lacked a system to monitor staff reviews and signatures of assessments.