HospitalInspections.org

Based on record review, interview and policy review, the facility failed to ensure that:

I. Initial Psychosocial Assessments for 4 out of 16 active sample patients (A7, A10, A14, and A15) were produced in a timely fashion. This failure results in the treatment team not having needed information on patient's baseline functioning to use in establishing goals and objectives.

II. The area of the Discharge Plans of the Psychosocial Assessments, which were to contain social work roles in treatment and discharge planning, were completed for 11 of 16 active sample patients (A5, A6, A7, A9, A10, A11, A12, A13, A14, A15, and A16). This failure results in a lack of social work input in treatment planning.

Findings include:

I. Late Psychosocial Assessments

Record Review
1. Patient A7 was admitted on 12/21/11; the Psychosocial Assessment was dated 12/27/11.

2. Patient A10 was admitted on 12/14/1; the Psychosocial Assessment was dated 12/22/11.

3. Patient A14 was admitted on 10/1/12; the Psychosocial Assessment was dated 10/18/12.

4. Patient A15 was admitted on 3/13/12; the Psychosocial Assessment was dated 3/22/12.

II. Incomplete Psychosocial Assessments

A. Record Review

1. Patient A5 was admitted on 6/14/09. In an annual Psychosocial Assessment dated 4/11/12, there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

2. Patient A6 was admitted on 8/19/10. In an annual Psychosocial Assessment dated 8/23/11, there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

3. Patient A7 was admitted on 12/21/11. In a Psychosocial Assessment dated 12/27/11 there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

4. Patient A9 was admitted on 11/1/11. In an annual Psychosocial Assessment dated 10/29/12, there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

5. Patient A10 was admitted on 12/14/11. In a Psychosocial Assessment dated 12/22/11, there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

6. Patient A11 was admitted on 8/16/12. In a Psychosocial Assessment dated 8/20/12, there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

7. Patient A12 was admitted on 3/4/08. In an annual Psychosocial Assessment dated 3/9/12 there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

8. Patient A13 was admitted on 12/28/11. In a Psychosocial Assessment dated 1/3/12 there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

9. Patient A14 was admitted on 10/1/12. In a Psychosocial Assessment dated 10/18/12 there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

10. Patient A15 was admitted on 3/13/12. In a Psychosocial Assessment dated 3/22/12 there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan section of the Psychosocial Assessment.

11. Patient A16 was admitted on 1/29/08. In an annual Psychosocial Assessment dated 1/11/11 there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan of the Psychosocial Assessment.

B. Interview

1. In an interview on 11/15/12 at 4:05 PM with the Chief Social Rehabilitation Executive (CSRE) and the Director of Social Services (DSW), after reviewing the records cited in Section A above, they confirmed there were no anticipated social work roles for treatment and discharge planning in the Discharge Plan section of the Psychosocial Assessment.

C. Policy Review

In the facility's "Social Work Manual Policy/Procedure", the policy titled "Social Data Base/Assessment" dated 9/2001, states in Section "Procedures," subsection 4.y - "Discharge planning alternatives......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 the:

I. Initial Psychosocial Assessments for 4 out of 16 active sample patients (A7, A10, A14, and A15) were produced in a timely fashion. This failure results in the treatment team not having needed information on patient's baseline functioning to use in establishing goals and objectives. (Refer to B108 Part I.)

II. The area of the Discharge Plans of the Psychosocial Assessments, which were to contain social work roles in treatment and discharge planning, were completed for 11 of 16 active sample patients (A5, A6, A7, A9, A10, A11, A12, A13, A14, A15, and A16). This failure results in a lack of social work input in treatment planning.

I. Findings include

A. Record Review

1. Patient A5 was admitted on 6/14/09. In an annual Psychosocial Assessment dated 4/11/12, there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

2. Patient A6 was admitted on 8/19/10. In an annual Psychosocial Assessment dated 8/23/11, there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

3. Patient A7 was admitted on 12/21/11. In a Psychosocial Assessment dated 12/27/11 there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

4. Patient A9 was admitted on 11/1/11. In an annual Psychosocial Assessment dated 10/29/12, there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

5. Patient A10 was admitted on 12/14/11. In a Psychosocial Assessment dated 12/22/11, there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

6. Patient A11 was admitted on 8/16/12. In a Psychosocial Assessment dated 8/20/12, there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

7. Patient A12 was admitted on 1/12/12. In a Psychosocial Assessment dated 3/9/12 there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

8. Patient A13 was admitted on 12/28/11. In a Psychosocial Assessment dated 1/3/12 there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

9. Patient A14 was admitted on 10/1/12. In a Psychosocial Assessment dated 10/18/12 there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

10. Patient A15 was admitted on 3/13/12. In a Psychosocial Assessment dated 3/22/12 there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

11. Patient A16 was admitted on 1/31/08. In an annual Psychosocial Assessment dated 1/11/11 there were no anticipated social work roles for treatment and discharge planning in the discharge plan of the Psychosocial Assessment.

B. Interview

1. In an interview on 11/15/12 at 4:05 PM with the Chief Social Rehabilitation Executive (CSRE) and the Director of Social Services (DSW), after reviewing the records cited in Section A above, confirmed there were no anticipated social work roles for treatment and discharge planning in the discharge plan section of the Psychosocial Assessment.

C. Policy Review

In the facility's "Social Work Manual Policy/Procedure", the policy titled "Social Data Base/Assessment" dated 9/2001, states in Section "Procedures," subsection 4.y: "Discharge planning alternatives... 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."