Failure to Document and Track Psychological Referrals
Penalty
Summary
The Director of Social Services (DSS) at the facility failed to develop and implement policies and procedures for identifying and addressing the medically related social and emotional needs of a resident. This deficiency was identified during a survey when it was found that a resident, who had been admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and Type 2 diabetes, had a mood score indicating moderate depression. Despite this, there was no documentation of a referral for a psychological assessment or evidence that such an assessment was completed. The DSS claimed to have verbally referred the resident for psychological services, but no written documentation was provided to support this claim. Interviews with the DSS, the psychologist, and the facility's administrator revealed a lack of formal tracking and documentation of psychological referrals and assessments. The DSS admitted that there was no formal system in place to track whether residents identified as needing psychological assessments received them or if the services were effective. The facility's administrator acknowledged the expectation that concerns identified in screenings should be followed up with documented referrals, but was unaware of the lack of formal tracking until the survey. The facility's job description for the DSS required the development and implementation of policies to address residents' social and emotional needs, which was not fulfilled in this case.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 NJ Ex Order 26.4(b) (1) at the facility. The Director of Social Services immediately conducted an audit of 100% of all residents to determine if their NJ Ex Order 26.4(b) (1) interview indicated a score of or greater, indicating the resident was NJ Ex Order 26.4(b)(1). The Director of Social Services identified 13 residents who had a score of or greater in section of the MDS and made a referral to the NJ Ex Order 26.4(b)(1) provider to ensure a NJ Ex Order 26.4(b)(1) assessment was conducted. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents with a Resident Mood Interview (RMI) of 10 or greater have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/27/2024 the Administrator provided in-service education to the U.S. FOIA (b) (6) with regards to the Directors responsibility which includes but is not limited to procedures for the identification of medically related social and emotional needs for residents and assisting residents in obtaining needed services from outside entities as needed. The Director of Social Services is the designated staff person who acts as the primary contact and coordinator for the contracted providers for psychiatry and psychology services. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Director of Social Services or designee will conduct audits of 5 residents weekly to review the score of the Resident Mood Interview (RMI). Residents with a RMI equal to or greater than 10 will be referred by the Director of Social Services to the contracted psychology provider for consult. The audits will be conducted weekly x 3 weeks, then monthly x 3 months. The results of the audits will be provided monthly x 3 months to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and comment. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.