Failure to Obtain Physician Orders for Third-Party Psychosocial Therapy Services
Penalty
Summary
The facility failed to ensure that psychosocial therapy services provided by a third-party Licensed Clinical Social Worker (LCSW) were delivered and documented according to professional standards. Specifically, the LCSW provided ongoing behavioral therapy to residents without obtaining physician's orders, and the facility did not have records of referrals, care plans, or notifications to resident representatives for these services. Interviews with facility staff, including the Social Services Director, RN, Assistant Director of Nursing, and the physician, confirmed that no physician's orders or referrals were in place for the residents receiving these services. The LCSW also did not share resident names or session documentation with the facility, citing confidentiality, and the facility's policy required physician's orders for all services provided to residents. Record reviews for three sampled residents revealed that each had received multiple sessions of cognitive behavioral therapy from the LCSW for conditions such as major depressive disorder and depression, despite having no documented behaviors or mood symptoms on their Minimum Data Set (MDS) assessments. The medical records for these residents did not contain any physician's orders reflecting the behavioral therapy they received. The deficiency was identified as having the potential to affect all 21 residents who received psychosocial therapy from the LCSW.