Failure to Maintain Full-Time Qualified Social Worker
Penalty
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.