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Based on record review and staff interview, the facility failed to provide social work assessments that included integration of factual and historical information into professional conclusions and recommendations for 8 of 8 active sample patients (A, B, C, D, E, F, G and H). This failure results in the absence of the identification of the social work role in treatment planning and discharge planning.

Findings include:

1. Record Review

Review of Inpatient Psychiatry Interdisciplinary Assessments with the subheadings of Treatment, Family, and Social History showed absence of social work conclusions and recommendations for 8 of 8 sample patients (evaluation date in parentheses): A (11/21/10), B (11/29/10), C (10/12/10), D (10/8/10), E (11/23/10), F (11/30/10), G (11/16/10), H (11/26/10).

2. Staff Interview

In an interview on 12/07/10 at 3:00PM, the Director of Social Work stated that the psychosocial assessments by the social workers were documented in the "Treatment, Family and Social History" section of the Inpatient Psychiatry Interdisciplinary Assessment. She further acknowledged that the social work conclusions and recommendations were missing in all 8 of 8 active sample patients' assessments. (A, B, C, D, E, F, G and H)

Based on record review and staff interviews, the facility failed to ensure that an assessment of memory functioning, orientation or estimation of intellect was part of the admission psychiatric evaluation for 3 of 8 sample patients. (A, G, H). This compromises the database from which diagnoses are determined and from which treatment interventions are established and measured.

Findings include:

A. Record Review

Review of the psychiatric evaluations of the following patients (evaluation date in parentheses) did not include estimation of intellect: A (11/21/10), G (11/11/10), H (11/25/10).

Review of the psychiatric evaluation of the following patient (evaluation date in parentheses) did not include estimation of memory or orientation: H (11/25/10).

B. Staff Interviews

1. In an interview on 12/07/10 at 2:30PM, Physician 1 acknowledged that estimation of intellect was missing in the psychiatric evaluations of patient G. "It was an oversight. I messed up."

2. In an interview on 12/07/10 at 4:15PM, the Acting Medical Director acknowledged that the estimation of intellect was missing in the psychiatric evaluation section of the Interdisciplinary Assessment for patients A, G and H. He further acknowledged that the estimation of memory and orientation were missing for patient H.

Based on record review and staff interviews, it was determined that the Medical Director failed to monitor and ensure that records included complete documentation with regard to memory, orientation, and intelligence.

Findings include:

A. Record Review

Review of the psychiatric evaluations of the following patients (evaluation date in parenthesis) did not include estimation of intellect: A (11/21/10), G (11/11/10), H (11/25/10).

Review of the psychiatric evaluation of the following patient (evaluation date in parenthesis) did not include estimation of memory or orientation: H (11/25/10).

B. Staff Interviews

1. In an interview on 12/07/10 at 2:30PM, Physician 1 acknowledged that estimation of intellect was missing in the psychiatric evaluation of patient G. "It was an oversight. I messed up."

2. In an interview on 12/07/10 at 4:15PM, the Acting Medical Director acknowledged that the estimation of intellect was missing in the psychiatric evaluation section of the Interdisciplinary Assessment for patients A, G and H. He further acknowledged that estimation of memory and orientation were missing for patient H.

Based on record review and staff interview, it was determined that the Social Services Director failed to monitor and ensure that records included integration of factual and historical information that was synthesized into professional conclusions and recommendations.

Findings include:

1. Record Review

Review of Inpatient Psychiatry Interdisciplinary Assessments with the subheadings of Treatment, Family, and Social History showed absence of social work conclusions and recommendations in 8 of 8 sample patients (evaluation date in parenthesis). A (11/21/10), B (11/29/10), C (10/12/10), D (10/8/10), E (11/23/10), F (11/30/10), G (11/16/10), H (11/26/10)

2. Staff Interview

In an interview on 12/07/10 at 3:00PM, the Director of Social Work stated that the psychosocial assessments by the social workers were documented in the "Treatment, Family and Social History" section of the Inpatient Psychiatry Interdisciplinary Assessment. She further acknowledged that the social work conclusions and recommendations were missing in all 8 of 8 active sample patients' assessments (A, B, C, D, E, F, G and H).

Based on record review, policy review and staff interview, the facility failed to provide individual therapeutic activities assessments for all patients in the sample (Records A, B, C, D, E, F, G, H). This deficiency resulted in the failure to identify individualized patient needs, and therefore the failure to provide therapeutic activities in a specific manner to meet each patient's needs.

Findings include:

1. Record Review

In 8 of 8 active records reviewed (A, B, C, D, E, F, G, H), therapeutic activities assessments were not present.

2. Policy Review

The facility Policy and Procedure titled "Inpatient Interdisciplinary Assessment" (effective Date 1/15/2008), with a stated purpose to "define the requirements for inpatient assessments," was reviewed. This policy did not include therapeutic activity assessments as a requirement for patient assessment.

3. Interview

In an interview on 12/7/10 at 2:30PM, with the Director of Rehabilitation and Volunteer Services, she confirmed that therapeutic activities assessments were not completed for patients admitted to the hospital.