Failure to Integrate Psychosocial Therapy Documentation into Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for all residents receiving individual psychosocial therapy. Specifically, a Licensed Clinical Social Worker (LCSW) provided therapy to approximately 21 residents but kept all therapy documentation in a locked cabinet, separate from the facility's medical record system. The LCSW did not share progress notes or any documentation with the facility, citing confidentiality, which resulted in incomplete medical records for residents receiving these services. Facility staff, including the Social Services Director, RN, and Assistant Director of Nursing, confirmed that they did not have access to information about which residents were receiving therapy or the details of the services provided. Record reviews for three sampled residents revealed that while the LCSW documented therapy sessions and treatment plans, this information was not integrated into the facility's records. The sampled residents had various diagnoses, including fibromyalgia, sacral spina bifida, and hemiplegia, and were cognitively intact according to their MDS assessments. Despite receiving regular cognitive behavioral therapy for depression or major depressive disorder, there was no documentation of these services in the facility's medical record system, leaving the records incomplete and inaccessible to the interdisciplinary team.