Based on interview, record review, and facility policy review, the facility failed to notify the physician and the resident's representative of the initiation of psychosocial services for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, and #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to ensure that the physician and resident representative (RR) were informed when 1:1 psychosocial therapy services were initiated by a third-party provider. Findings Included: A review of the facility's Resident Rights Notification of Changes Policy, reviewed date 05/30/2025 revealed, It is the policy of (Proper Name of Facility) to notify the resident; consult with the physician; and notify, consistent with his or her authority, the resident representative of changes as discussed in the policy . On 6/11/25 at 11:00 AM, a phone interview with the complainant revealed that there is a Licensed Certified Social Worker (LCSW) that is not employed by the nursing home facility (3rd Party Provider) who comes to the facility to provide psychosocial therapy to several residents. The complainant stated that LCSW refuses to share the names of the residents she provides services to, which prevents the facility from notifying the residents' Responsible Representatives (RRs) and the physician of new treatments or interventions. The complainant expressed concern that when the physician is not notified, there is no opportunity to review, approve, or coordinate the therapy with the resident's overall medical plan of care. This could result in duplicate or conflicting treatments, overlooked medication considerations, or a missed opportunity to address any underlying conditions. Additionally, the complainant was concerned that failure to notify the RR limits their ability to monitor the resident's care and make informed decisions on their behalf and advocate effectively for the resident's needs, especially if the resident has limited insight. On 6/12/25 at 10:00 AM, in an interview with the facility's Social Services staff member, she confirmed that the LCSW is from the local hospital and enters the facility on Thursdays to provide therapy on residents within the facility. She does not inform the facility's staff, Psychiatric Nurse Practitioner (NP), or the physician who she is providing therapy for. Therefore the facility is unable to notify the RR of any new orders or treatments of her services. On 6/12/25 at 10:30 AM, in an interview, the LCSW confirmed that she has provided the behavioral services to approximately 21 residents at the facility. She revealed that the residents are self-referrals, and they all have a Brief Interview for Mental Status (BIMS) score of 13 or greater. The LCSW stated that she does not provide any information regarding these residents to the nursing staff or the facility, because it is confidential. On 6/12/25 at 10:45 PM, during an interview, Registered Nurse (RN) #1 stated that she was not aware of which residents were receiving psychosocial therapy services from the LCSW in the facility. She confirmed that, as a result, no physician orders had been obtained for the service, and the facility had not notified the residents' RRs of the initiation of therapy. RN #1 acknowledged that the facility has a written policy requiring physician involvement and RR notification prior to any changes in treatment and confirmed that this policy had not been followed for residents receiving psychosocial services from the LCSW. On 6/12/25 at 11:10 AM, during an interview, the Administrator confirmed that the LCSW was providing psychosocial therapy services to residents within the facility. The Administrator stated that all referrals were initiated by the residents themselves. He acknowledged that the facility did not follow its policy requiring RR and physician notification. On 6/12/25 at 1:27 PM, during an interview, the Nurse Practitioner/Psych confirmed that she was not aware that the LCSW evaluated or performed sessions with Resident #4, #5, and #6. She explained there was no referral provided to the facility on which residents the LCSW was providing treatment. On 6/12/25 at 1:45 PM, during an interview with the Physician, he confirmed that he was not aware of and had not issued any referrals for Residents #4, #5, or #6 to receive psychosocial evaluations or treatment. A record review of the facility's statement, dated 6/12/25, and signed by the Administrator revealed, The facility did not have a referral for (Proper Name of LCSW), no care plan, and no notification of resident representative . regarding Resident #4, Resident #5, and Resident #6. A record review of the LCSW resident service list revealed that she had provided psychosocial services to 21 residents, including Resident #4, Resident #5, and Resident #6. A record review of the medical records for Resident #4, Resident #5, and Resident #6 revealed there were no documentation indicating the RRs or they physician's were notified regarding behavioral therapy received by the residents. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/25 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression . Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on record review, interview, and facility policy review, the facility failed to develop a comprehensive care plan that included all services provided to address the psychosocial needs of three (3) of three (3) sampled residents receiving individual psychosocial therapy (Residents #4, #5, and #6), with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to include ongoing psychosocial therapy services provided by the Licensed Clinical Social Worker (LCSW) in the residents care plans to ensure coordination of care, consistent monitoring, and individualized interventions based on the residents' psychosocial needs. Findings included: A review of the facility's Comprehensive Person-Centered Care Plan Policy, reviewed on 1/24/2024, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered plan of care for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . During a phone interview on 6/11/25 at 11:00 AM, the complainant revealed that there are no care plans related to behavioral therapy received by residents seen at the facility by a LCSW. She explained the LCSW is not employed by the nursing home facility (3rd Party Provider) and she refuses to share any information regarding the residents to which she provides services. On 6/12/2025 at 10:00 AM, during an interview with the facility's Social Services Director, she confirmed there are no behavioral care plan interventions that includes the services provided by the LCSW that visits the facility. On 6/12/2025 at 10:30 AM, during an interview with the LCSW, she confirmed that she has seen approximately 21 residents in the facility, and she does not provide the name of the residents or any information to the facility due to confidentiality. On 6/12/2025 at 10:45 AM, during an interview with Registered Nurse (RN) #1, she stated that there was no documentation or Physician's Orders provided to the facility by the LCSW and as a result, care plans were not developed for residents receiving behavioral therapy. On 6/12/2025 at 11:00 AM, during an interview with Licensed Practical Nurse (LPN)/MDS Coordinator #1, she confirmed that Residents #4, #5, and #6 did not have care plans reflecting services provided by the LCSW. She stated that comprehensive care plans are important to ensure residents receive individualized care. She further stated that although Section D of the MDS captured mood concerns on occasion, these were not cross-referenced with therapy services provided by the LCSW, since the facility was not informed of the sessions. On 6/12/2025 at 11:30 AM, during an interview with the Assistant Director of Nursing (ADON), she confirmed that all services provided to residents, including psychosocial therapy, should be incorporated into the resident's care plan. She stated the LCSW has refused to collaborate with the team or provide documentation, which prevented the facility from creating care plans reflecting these services. On 6/12/25 at 11:45 AM, during an interview with the Administrator, he confirmed there is no indication that the interdisciplinary team was involved in developing or reviewing care plans related to psychosocial therapy services provided by the LCSW. A record review of the facility's statement, dated 6/12/25, and signed by the Administrator revealed, The facility did not have a referral for (Proper Name of LCSW), no care plan, and no notification of resident representative . regarding Resident #4, Resident #5, and Resident #6. A record review of the LCSW resident service list revealed that she had provided psychosocial services to 21 residents, including Resident #4, Resident #5, and Resident #6. A record review of the medical records for Resident #4, Resident #5, and Resident #6 revealed there were no care plan interventions developed reflecting behavioral therapy received by the residents from the LCSW. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression. Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on record review, interview, and facility policy review, the facility failed to ensure services were provided and documented according to professional standards for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to obtain a physician's order for ongoing psychosocial therapy services provided by a third party Licensed Clinical Social Worker (LCSW), resulting in services being delivered without appropriate physician oversight. Findings included: A review of the facility policy titled, Physician Orders, reviewed 01/24/2024, revealed, .Scope: Physician's orders that will be obtained, noted, and implemented appropriately . During a phone interview on 6/11/25 at 11:00 AM, the complainant revealed that there are no Physician's Orders for residents who are seen at the facility by a LCSW for behavioral therapy. She explained the LCSW is not employed by the nursing home facility (3rd Party Provider) and she refuses to share the names of the residents to which she provides services. During an interview on 6/12/2025 at 10:00 AM, the facility's Social Services Director confirmed there were no Physician's Orders for behavioral therapy services that are provided to the residents by the visiting LCSW. During an interview on 6/12/2025 at 10:30 AM, the LCSW confirmed she does not provide resident names to the facility due to confidentiality nor provides them with any documentation of her sessions with the residents. She stated she has seen approximately 21 residents in the facility. On 6/12/2025 at 10:45 AM, during an interview with Registered Nurse (RN) #1, she confirmed there are no Physician's Orders for the residents who are seen by the LCSW regarding behavioral services. On 6/12/2025 at 11:30 AM, during an interview with the Assistant Director of Nursing (A-DON), she confirmed that all services provided to residents, including psychosocial therapy, should have a Physician's Order. On 6/12/25 at 1:45 PM, during an interview with the Physician, he confirmed there were no orders or referrals for Resident #4, #5, and #6 and without physician orders, the facility was unable to ensure that services provided by the LCSW were appropriate to the resident's diagnoses or current mental health status. A record review of the facility's statement, dated 6/12/25, and signed by the Administrator revealed, The facility did not have a referral for (Proper Name of LCSW), no care plan, and no notification of resident representative . regarding Resident #4, Resident #5, and Resident #6. A record review of the LCSW resident service list revealed that she had provided psychosocial services to 21 residents, including Resident #4, Resident #5, and Resident #6. A record review of the medical records for Resident #4, Resident #5, and Resident #6 revealed there were no Physician's Orders initiated reflecting behavioral therapy received by the residents. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression. Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on record review, interview, and facility policy review, the facility failed to identify, assess, and coordinate behavioral health services for three (3) of three (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, and #6, with the potential to affect all 21 residents receiving these services. Specifically, the facility allowed a Licensed Certified Social Worker (LCSW) to provide ongoing cognitive behavioral therapy within the facility without physician oversight, formal referral, or interdisciplinary coordination in which she accepted self-referred residents, regardless of whether clinical need had been identified. Findings Included: A review of the facility's policy, Dementia and Behavioral Health Services, reviewed 02/28/2024, revealed, .It is the policy of this facility that all residents receive the appropriate treatment and services for .necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning .Discussion .6. Specialized services and supports will vary based on the individual's abilities and challenges related to their condition . On 6/11/2025 at 11:00 AM, during a phone interview, the complainant stated that a Licensed Clinical Social Worker (LCSW), employed by the local hospital's behavioral health program, came to the facility weekly and provided therapy sessions to several residents. The complainant explained that the LCSW refused to disclose the names of the residents she was seeing, which prevented the facility from coordinating care, obtaining physician oversight, or monitoring for changes in residents' psychosocial or behavioral health status. She expressed concern that residents may have been receiving therapy without proper clinical justification or oversight, and that the lack of transparency and interdisciplinary involvement could result in unmet needs, fragmented care, or inappropriate continuation of services for vulnerable residents. On 6/12/2025 at 10:00 AM, during an interview with the Social Services Director, she confirmed that the Licensed Clinical Social Worker (LCSW) enters the facility every Thursday to provide therapy services. However, she stated the LCSW does not communicate with facility staff, the Nurse Practitioner (NP), or the physician regarding which residents are receiving services. As a result, the facility is unable to conduct appropriate psychosocial assessments or implement monitoring interventions to evaluate the effectiveness or necessity of the therapy. On 6/12/2025 at 10:30 AM, during an interview with the LCSW, she stated that she had provided therapy services to approximately 21 residents. She explained that all referrals were self-referral by residents who were cognitively intact, with Brief Interview for Mental Status (BIMS) scores of 13 or higher. The LCSW stated that, due to confidentiality, she does not inform facility staff or medical personnel of the residents receiving therapy. She confirmed that the residents independently request services and that she has a pamphlet in the facility's front lobby containing information about her services and contact details. On 6/12/2025 at 10:45 AM, during an interview with Registered Nurse (RN) #1, she confirmed that the LCSW did not communicate with nursing staff regarding which residents were receiving therapy. Therefore, there was no coordination of care since there were no physician orders, no behavioral health monitoring or follow-up, as the staff was unaware that therapy services were being provided. On 6/12/2025 at 11:15 AM, during an interview with the Assistant Director of Nursing (ADON), she confirmed that the facility does not receive any information regarding the residents receiving therapy from the LCSW and therefore the facility was unable to initiate monitoring or coordinate care for those residents. On 6/12/25 at 11:30 AM, during an interview, the Administrator confirmed the facility did not coordinate care or provide oversight of the behavioral health services provided by the LCSW which could result in care that conflicts with residents' overall treatment goals. On 6/12/2025 at 1:27 PM, during an interview with the Nurse Practitioner (NP)/Psychiatric Provider, she confirmed that she was not aware the Licensed Clinical Social Worker (LCSW) was providing therapy services to Residents #4, #5, or #6. She stated that she had not issued any referrals for therapy and had not conducted any follow-up monitoring for those residents. On 6/12/2025 at 1:45 PM, during an interview with the Physician, he confirmed that he had not ordered behavioral health therapy for Residents #4, #5, or #6 and was unaware they were receiving such services. He stated that without this information, he was unable to assess their psychosocial status or provide appropriate medical oversight. A record review of a pamphlet displayed in the facility's front lobby titled NOW OFFERING Psychotherapy Services revealed a brochure containing provider details and contact information for the Licensed Clinical Social Worker (LCSW) offering behavioral health services. A record review of the facility's statement, dated 6/12/25, and signed by the Administrator revealed, The facility did not have a referral for (Proper Name of LCSW), no care plan, and no notification of resident representative . regarding Resident #4, Resident #5, and Resident #6. A record review of the LCSW resident service list revealed that she had provided psychosocial services to 21 residents, including Resident #4, Resident #5, and Resident #6. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression. Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on interview, record review, and facility policy review, the facility failed to ensure complete and readily accessible medical records were maintained for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the therapist maintained resident therapy documentation separately from the facility's medical record and did not share or integrate the documentation into the residents' facility medical records. Findings included: A review of the facility's policy titled, Medical And Personal Resident Records, reviewed 01/24/2024, revealed, .It is the policy .that the resident's personal and medical records shall be maintained in accordance with professional standards and practice Discussion: 1. The medical record shall be completely and accurately documented, readily accessible .to facilitate retrieval and compiling of information . On 6/11/2025 at 11:00 AM, during a phone interview with the complainant, she stated that a Licensed Clinical Social Worker (LCSW), employed by the local hospital's behavioral health department, provided therapy to several residents and stored all related documentation in a locked cabinet to which only the LCSW had access. The complainant reported that the LCSW refused to allow the Interdisciplinary Team (IDT) to review these records. As a result, the facility's medical record for each resident receiving these services was incomplete due to lack of access to pertinent clinical information. On 6/12/2025 at 10:00 AM, during an interview with the facility Social Services Director, she confirmed that the Licensed Clinical Social Worker (LCSW) visits the facility on Thursdays and independently provides therapy to residents. She stated that the LCSW does not share progress notes or any other documentation related to the services being provided. On 6/12/2025 at 10:30 AM, during an interview with the Licensed Clinical Social Worker (LCSW), she stated that she had provided therapy services to approximately 21 residents in the facility. The LCSW confirmed that she does not provide the facility with any documentation related to the services rendered, citing confidentiality. On 6/12/2025 at 10:45 AM, during an interview with Registered Nurse (RN) #1, she stated that she was not aware of which residents LCSW was treating, and there was no documentation available within the facility ' s medical record system regarding the therapy services rendered by the LCSW. On 6/12/2025 at 11:30 AM, during an interview with the Assistant Director of Nursing (A-DON), she confirmed that all services provided to residents, including psychosocial therapy, should be incorporated into the resident ' s computerized charting system at the facility. The absence of documentation in the facility ' s record system prevented staff, physicians, and interdisciplinary team members from being aware of ongoing therapy services. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression. Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on staff interview and record review, the facility failed to electronically submit accurate direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for one (1) of three (3) months reviewed. December 2023 Findings include: A review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility had triggered for Four or More Days Within the Quarter with no RN (Registered Nurse) Hours and Four or More Days Within the Quarter with <24 Hours/Day Licensed Nursing Coverage from 12/2/23 to 12/31/23. Record review of facility policy Nurse Staffing Information, revised 11/14/23, revealed it did not address the accurate submission of PBJ data. On 5/13/24 at 12:48 PM, the Business Office Coordinator stated she was unaware the facility failed to electronically submit PBJ staffing data to CMS accurately in the first quarter of FY (Fiscal Year) 2024. She explained she was responsible for entering the PBJ data for the facility and kept the receipts which indicated the data was sent. She stated she did not receive any type of error message, warning, or email after the information was submitted that would have indicated the information was not accurate. During an interview on 5/14/24 at 10:48 AM, with the Director of Nursing (DON), she stated she was not aware there was an error with the data that was submitted to PBJ for the first quarter of FY 2024. The DON explained she was responsible for creating the nursing schedules and confirmed the facility always had adequate nursing staff and had 24-hour RN coverage. She stated she had not received any type of email or had any indication staffing data for December 2023 had not been submitted accurately. On 5/14/24 at 1:51 PM, the Administrator stated she was unaware there was an issue related to the accuracy of the PBJ data that was submitted to CMS for the first quarter of FY 2024. The Administrator confirmed the Business Office Coordinator was responsible for entering and submitting the PBJ staffing data for the facility. The Administrator said there was an interface error that occurred, and the staffing data was not collected from 12/2/23 through 12/31/23. She confirmed there was no shortage of nursing staff or RN coverage for December 2023. The Administrator reported that she would not have known the data was entered incorrectly because she did not receive any feedback by email or otherwise that would have alerted her than an error had been made, but ultimately it was the responsibility of the facility to ensure the information submitted was accurate.