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Based on record review, interview, and policy review, the facility failed to ensure that Psychosocial Assessments were completed for 4 of 12 active sample patients (A1, A9, A10 and A11) and one additional patient (A16) whose medical record was reviewed. This failure results in a lack of social work input in treatment planning.

Findings include:

A. Record Review

1. Patient A1 was admitted to the Adult Acute Unit on 6/5/12. The psychosocial assessment dated 6/8/12, included no anticipated social work roles for treatment and discharge planning in the Biopsychosocial Summary/Clinical Formulation section of the psychosocial assessment.

2. Patient A9 was admitted to the Adult Acute Unit on 6/6/12 at 11:55PM. There was no psychosocial assessment as of 6/12/12 at 10:30AM.

3. Patient A10 was admitted to the Adult Acute Unit on 6/8/12 at 1PM. There was no psychosocial assessment as of 6/12/12 at 10:30AM.

4. Patient A11 was admitted to the Adult Acute Unit on 6/8/12 at 4PM. There was no psychosocial assessment as of 6/12/12 at 10:30AM.

5. Patient A16 was admitted to the Adult Acute Unit on 6/7/12 at 8PM. There was no psychosocial assessment as of 6/12/12 at 10:30AM.

B. Interview

1. In an interview on 6/11/12 at 3:25PM, the Corporate Director of Compliance and Communication confirmed that the psychosocial assessment for Patient A9 was not in the record and stated "He (Patient A9) is on the list to do" for the Director of Social Work.

2. In an interview on 6/12/12 at 3:15 PM, after reviewing the records, the Director of Social Work stated: "I'm not caught up; I didn't do the assessments for these patients (A9, A10, A11 and A16). I thought I had finished this one (Patient A1)."

C. Policy Review

In the facility's "Clinical Manual Policy/Procedure," the policy titled "Integrated Assessment Guidelines" dated 2/2012 states on page 2, section 3: "The psychosocial assessment is completed within 72 hours of admission. The assessment summary synthesizes data from all the assessments and develops a case formulation identifying treatment needs including: Anticipated social work role(s) in treatment and discharge planning."

Based on record review, interview and policy review, the Director of Social Work failed to
ensure that Psychosocial Assessments were completed for 4 of 12 active sample patients (A1, A9, A10, A11) and one additional patient )A16) whose medical record was reviewed. This failure results in a lack of social work input in treatment planning.

Findings include:

A. Record Review

1. Patient A1 was admitted to the Adult Acute Unit on 6/5/12. In a psychosocial assessment dated 6/8/12, there were no anticipated social work roles for treatment and discharge planning in the Biopsychosocial Summary/Clinical Formulation section of the psychosocial assessment.

2. Patient A9 was admitted to the Adult Acute Unit on 6/6/12 at 11:55PM. There was no psychosocial assessment as of 6/12/12 at 10:30AM.

3. Patient A10 was admitted to the Adult Acute Unit on 6/8/12 at 1PM. There was no psychosocial assessment as of 6/12/12 at 10:30AM.

4. Patient A11 was admitted to the Adult Acute Unit on 6/8/12 at 4PM. There was no psychosocial assessment as of 6/12/12 at 10:30AM.

5. Patient A16 was admitted to the Adult Acute Unit on 6/7/12 at 8PM. There was no psychosocial assessment as of 6/12/12 at 10:30AM.

B. Interview

1. In an interview on 6/11/12 at 3:25PM, the Corporate Director of Compliance and Communication confirmed that the psychosocial assessment for Patient A9 was not in the record and stated "He (Patient A9) is on the list to do" for the Director of Social Work.

2. In an interview on 6/12/12 at 3:15PM, after reviewing the records, the Director of Social Work stated, "I'm not caught up; I didn't do the assessments for these patients (A9, A10, A11 and A16). I thought I had finished this one (Patient A1)."

C. Policy Review

In the facility's "Clinical Manual Policy/Procedure" the policy titled "Integrated Assessment Guidelines" dated 2/2012, states on page 2, section 3: "The psychosocial assessment is completed within 72 hours of admission. The assessment summary synthesizes data from all the assessments and develops a case formulation identifying treatment needs including: Anticipated social work role(s) in treatment and discharge planning."