Failure to Notify Physician and Resident Representative of Initiation of Psychosocial Therapy
Penalty
Summary
The facility failed to notify the physician and the resident representative (RR) when individual psychosocial therapy services were initiated for three sampled residents, with the potential to affect all 21 residents receiving such therapy. According to the facility's policy, notification of the resident, consultation with the physician, and notification of the RR are required when there are changes in treatment or services. However, a Licensed Certified Social Worker (LCSW) from a third-party provider delivered psychosocial therapy to residents without informing facility staff, the physician, or the RRs. The LCSW stated that all referrals were self-initiated by cognitively intact residents and did not share information about which residents were receiving services, citing confidentiality. Interviews with facility staff, including the Social Services staff member, Registered Nurse, Nurse Practitioner, and the physician, confirmed that they were unaware of which residents were receiving therapy from the LCSW. As a result, no physician orders were obtained, and no notifications were made to the RRs regarding the initiation of therapy. The Administrator acknowledged that the facility did not follow its own policy for physician and RR notification for residents receiving psychosocial services from the LCSW. Record reviews for the three sampled residents showed that each had a BIMS score indicating they were cognitively intact and had no documented behaviors or mood symptoms at the time of assessment. Documentation from the LCSW confirmed that these residents received Cognitive Behavioral Therapy for depression on multiple occasions, but there was no evidence in the medical records that the physician or RRs were notified about the initiation or continuation of these services.