Failure to Maintain Full-Time Qualified Social Worker
Summary
The facility failed to employ a qualified full-time Licensed Social Worker (LSW) as required for facilities with more than 120 beds, affecting all residents in need of social services. The last full-time LSW left the facility on 5/23/25, and since then, there was no qualified individual consistently fulfilling the role. The facility census was 151 residents, and the absence of a full-time LSW resulted in lapses in required social services documentation, assessments, and participation in care planning for multiple residents with significant mental health and psychosocial needs. Record reviews for several residents revealed that there were no social worker progress notes or social services interventions documented for extended periods following the departure of the LSW. For example, one resident with diagnoses including schizophrenia and sickle-cell disease had no social worker notes from January through the present, and no evidence of social services involvement in critical processes such as sexual consent forms. Similar gaps were found for other residents with complex psychiatric and behavioral diagnoses, including a lack of social services assessments, absence from care plan meetings, and no input on important documentation such as sexual consent forms. Interviews with facility staff and external partners confirmed the deficiency. The administrator acknowledged the absence of a full-time LSW and stated that a consultant was only available for questions and not present daily or performing the full scope of LSW duties. The consultant LSW confirmed they were not acting as the facility's LSW and only provided limited assistance. The regional director of operations noted that a non-licensed staff member had temporarily filled the role, but this did not meet regulatory requirements. The Ombudsman reported not receiving required discharge logs for two months, which had previously been provided by the LSW, further evidencing the breakdown in social services processes.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility licensed for 187 beds failed to maintain a qualified full-time social worker after the licensed social worker resigned. The Administrator stated that an unlicensed social worker was hired to assist and remained listed as the social worker while the facility interviewed applicants for a licensed replacement. The Social Services policy described the social worker role as including discharge planning, psychosocial coordination, and interdisciplinary communication.
Unqualified Social Service Director: The facility failed to ensure the SSD met the minimum qualifications for the role for a census of 135. The SSD stated she had a BA in Communications, while HR confirmed the job description required a BA in Social Work or Human Services plus 2 years of supervised social work experience in a health care setting, and said the degree was not verified.
Failure to Employ a Qualified Full-Time SW: The facility did not have a full-time qualified SW after the SW was suspended and later terminated, leaving only a Social Worker Assistant who was not licensed and did not meet federal qualification requirements. The Assistant handled discharge planning, progress notes, notices, and referrals without SW oversight, while many residents had MH diagnoses and some had SUD diagnoses.
No full-time social worker was maintained at the facility despite having more than 120 beds. Record review showed no social worker on the staff list, and interviews with the ADON, BOM, DON, and Administrator confirmed the facility had relied on a corporate social worker who came weekly or occasionally, with other staff helping cover social work needs.
A facility licensed for 123 beds failed to employ a qualified full-time social worker for about two months. The current SSA was not a licensed social worker and had no social work degree or human services bachelor's degree, yet was completing admissions, discharges, and resident assistance while the Administrator, DON, BOM, management team, and sister facilities provided informal support.
Unlicensed Social Worker Not Employed Full-Time: The facility failed to ensure a qualified social worker was employed full-time for the social services position. The SW was listed as unlicensed, had a passing ASWB master's exam score and preliminary Texas licensure requirements, but did not have a current license. The SW reported working independently after orientation without routine supervision, while the HR Manager and Administrator confirmed the lack of licensure and the absence of routine oversight or a written hiring policy.
Unlicensed Social Worker Used in Place of Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed. The facility was licensed for 187 beds, and during interview and record review on 07/02/26 at 5:25 p.m., the Administrator stated that the employee list showed Social Worker R as an unlicensed social worker. He said he hired Social Worker R on 04/03/26, when the person was unlicensed, to assist the previously licensed social worker who had resigned on 05/30/26. The Administrator said he was interviewing applicants to hire a licensed social worker as soon as possible. The facility’s Social Services policy stated that the social worker role includes discharge planning to ensure safe transitions of care, regulatory compliance, and coordination with residents, families, and the interdisciplinary team.
Unqualified Social Service Director
Penalty
Summary
The facility failed to ensure the Social Service Director met the minimum qualifications for the position for a census of 135 residents. During interview, the Social Service Director stated she had a Bachelor's Degree in Communications. The Human Resources Director confirmed that the job description required a Bachelor's degree in Social Work or a Human Services field and two years of supervised social work experience in a health care setting, and stated he did not verify the Social Service Director's degree as listed on her resume. Record review of the facility's license showed 168 beds, and the cited deficiency was based on the facility's failure to have a qualified full-time social worker for a facility with more than 120 beds.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time qualified Social Worker in a building licensed for 123 beds that admitted residents with psychosocial care needs related to mental illness, substance use disorder, and behavioral issues. The facility’s policy stated that all residents should receive necessary behavioral health services and that Social Services should serve as the contact person for behavioral services. Review of the census showed 99 occupied beds, and review of the resident analyzer report showed that 5 residents had substance use disorder diagnoses and 81 residents had one or more mental health diagnoses. Social Worker #1 was suspended on 05/28/26 during an abuse investigation and her employment was terminated on 06/03/26. After that, the facility had only a Social Worker Assistant, who worked full-time but was not licensed and did not have a bachelor’s degree in an acceptable field, so she did not meet the qualifications of a full-time qualified social worker. The Social Worker Assistant stated she had been the only social service staff member since the departure of SW #1, had no oversight from a social worker, and the facility had no contract with outside social service providers. The Administrator confirmed that the facility had not employed a full-time qualified social worker since 05/28/26 and had no outside agreement to provide social services during the vacancy.
No Full-Time Social Worker
Penalty
Summary
Failure to maintain a full-time social worker in a facility with more than 120 beds was identified based on record review and staff interviews. Review of the current staff list showed no social worker employed at the facility. The Assistant DON stated the facility had not had a full-time social worker since roughly January 2026, and that a corporate social worker came into the building occasionally while other staff, including nurse management, assisted with social work needs. The BOM reported there was no social worker except a corporate worker who came weekly, and that the BOM and other staff members helped with social work activities. The DON stated the facility previously had a social worker who came on weekends but was terminated roughly ten days before the interview, and that the facility currently had a corporate social worker who came once per week. The Administrator confirmed the facility had not had a full-time social worker since joining the facility in January 2026.
No Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to ensure a qualified social worker was employed on a full-time basis for approximately two months in a building licensed for 123 beds and serving 94 residents. During observation of the facility license and review of the Facility Assessment, the facility was confirmed to be licensed and certified for 123 beds. Review of the Social Services/Social Worker Assistant job description showed the role was intended to support the overall operation of the Social Services Department, but the employee in the position was a Social Services Assistant rather than a licensed social worker. Interviews and personnel record review showed the Social Services Assistant had been hired on 04/22/26 and did not have a social worker degree, certification, or bachelor's degree in a human services field. The SSA stated she had been working as the assistant social worker since mid-April 2026, had been completing admissions, discharges, and assisting residents, and that there had been no licensed social worker in the building since that time. The Administrator and DON stated the previous social worker left in late May or early April 2026, that the current person in the role was the SSA and was not a certified social worker, and that the facility had been relying on the BOM, management team, sister facilities, and borrowed help while trying to hire a social worker.
Unlicensed Social Worker Not Employed Full-Time
Penalty
Summary
The facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed. The facility was licensed for 154 beds, and the social worker position was identified as unlicensed on the employee roster provided by the DON. Record review showed a job offer letter dated 02/09/2026 with an official start date of 02/23/2026, and criminal history verification listed a hire date of 02/05/2026 with a first day of service on 02/23/2026. Record review of an email from the Association of Social Work Boards showed that the social worker had a passing score on the ASWB master's examination and had received preliminary requirements for licensure in Texas. During interview, the social worker stated she had worked at the facility since February 2026, had been told she needed to obtain her license within six months, and had worked independently after a 30-day orientation without routine supervision or review. The HR Manager stated the social worker had an offer letter requiring licensure within six months, but the facility did not have documentation verifying the letter or completion of licensure, and confirmed the social worker did not possess a current license and was not permitted to practice independently. The Administrator stated he was aware the social worker did not have a license, and the HR Manager stated the facility did not have a written policy regarding the hiring process for anyone at the facility, including the social worker.
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