Failure to Provide Medically-Related Social Services and Care Planning
Penalty
Summary
The facility failed to provide medically-related social services to all eight residents reviewed, resulting in unmet social service needs. Several residents did not receive support with the care planning process, as evidenced by missing or incomplete documentation of care conferences and lack of communication with residents and their families. For example, one resident's family member, who was the power of attorney, reported a lack of updates and care conferences, despite the resident's declining condition. Another resident expressed frustration over not receiving assistance from social services to address a Medicaid-related issue due to physical limitations, and there was no documentation of recent care conferences for this resident. The facility also failed to provide support for advance directive (AD) formulation and discharge planning. Two residents had no documentation or evidence of being assisted with ADs, and their care plans did not address this area. Additionally, two residents were not kept informed about their discharge plans, with one resident and their family left uncertain about the discharge process and another resident expressing concern about financial matters related to discharge. Documentation in the electronic health records was lacking, and there were no recent notes or updates regarding discharge planning for these residents. Furthermore, the facility did not complete referrals or follow up on recommendations for appropriate mental health services for residents with depression or other mental health diagnoses. In one case, a resident had a psychological evaluation with recommendations, but there was no update to the plan of care by social services. Another resident's PASARR assessment was found to be inaccurate and not updated for a necessary level II evaluation. The facility's social services department was understaffed during this period, with key staff positions vacant or on leave, and temporary support from another facility was being used to cover essential social work tasks.