Failure to Include LCSW Psychosocial Therapy in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the psychosocial needs of residents receiving individual therapy from a Licensed Clinical Social Worker (LCSW). Specifically, the care plans for three sampled residents did not include the ongoing psychosocial therapy services provided by the LCSW, nor did they reflect coordination of care, consistent monitoring, or individualized interventions based on the residents' psychosocial needs. This omission was identified through record reviews, interviews with facility staff, and review of facility policy, which requires that all identified needs, including mental and psychosocial, be addressed in the care plan with measurable objectives and timeframes. Interviews with facility staff, including the Social Services Director, RN, LPN/MDS Coordinator, and ADON, confirmed that there were no behavioral care plan interventions or documentation related to the LCSW's services. The LCSW, who is a third-party provider and not employed by the facility, refused to share information about the residents she served, citing confidentiality. As a result, the facility was not informed of the therapy sessions, and no physician's orders or documentation were provided to support the inclusion of these services in the residents' care plans. The interdisciplinary team was not involved in developing or reviewing care plans related to these psychosocial therapy services. Record reviews for the three residents showed that each had received cognitive behavioral therapy from the LCSW for depression or major depressive disorder, with therapy provided on a regular basis. Despite this, their medical records and care plans did not reflect these services or any related interventions. The lack of documentation and care planning for these services affected not only the three sampled residents but also had the potential to impact all 21 residents who received psychosocial therapy from the LCSW.