Unqualified Social Services Director and Failure to Provide Required Social Services
Summary
The facility failed to ensure that the Social Services Director (SSD) met the required qualifications to manage and coordinate social services for its 126 residents. The SSD held a Bachelor of Science in Psychology and was working toward a master's in social work, but this was her first experience in a skilled nursing facility. During interviews and record reviews, it was found that the SSD had not facilitated several required social services, including providing Advance Directive information to six sampled residents or their representatives, making dental and podiatry referrals as ordered, and completing initial social history assessments. The SSD also reported not conducting resident visits in their rooms, instead waiting for care conferences, and delayed documentation for up to two days. Further review revealed that the SSD did not notify the Ombudsman regarding a resident's transfer and discharge, believing it was not her responsibility, and failed to appropriately assess and refer three residents for Pre-admission Screening and Resident Review (PASRR). The facility's policies and job descriptions outlined responsibilities for the SSD that were not being met, such as maintaining adequate records, making necessary referrals, and providing supportive visits. The Director of Nursing confirmed awareness of these occurrences during the survey.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility, licensed for more than 120 Medicare/Medicaid beds, did not employ a full-time qualified LSW as required. Personnel records showed that the person functioning in the social services role had been hired as a CNA and later promoted to social services but did not hold a social work license. In an interview, the Administrator confirmed both the regulatory requirement for a full-time LSW and that no LSW was employed at the facility.
The facility, with a census of 135 residents, failed to employ a Licensed Social Worker (LSW) as required. Instead, a Social Work Consultant (SWC) without a social work license was providing services. The Administrator mistakenly believed the SWC was licensed and only realized the error after requesting her credentials. This deficiency was identified during a complaint investigation.
The facility failed to ensure that a social worker hired for a 126-bed facility had the required one year of supervised experience in a healthcare setting. The personnel file lacked evidence of such experience, and interviews with staff confirmed the absence of documentation. This deficiency potentially affected all 115 residents.
The facility did not employ a full-time, qualified social worker, affecting all 116 residents. The last social worker was hired and terminated within a few months, and the Administrator incorrectly believed the facility was licensed for fewer beds than required for this position.
The facility did not employ a full-time, qualified social worker, affecting 139 residents. The Social Service Director had a degree in business administration, not in social work or a human services field. The last licensed social worker left in December 2024, and interviews confirmed the absence of a licensed social worker during the survey.
The facility failed to employ a qualified social worker despite having over 120 certified beds. SSD #320, introduced as the new social worker, had a Master's degree but had not passed the State licensing exam and was not licensed. The Administrator was aware of this at the time of hiring. The job description required a Bachelor's Degree, supervisory experience, and ACSW registration, which SSD #320 did not meet. This deficiency potentially affected all 109 residents.
Failure to Employ Required Full-Time Licensed Social Worker
Penalty
Summary
The facility failed to employ a full-time qualified Licensed Social Worker (LSW) despite being licensed for 126 Medicare/Medicaid beds and having a census of 119 residents, which required a full-time LSW. Review of personnel records showed that the individual serving in the social services role, identified as Social Service Worker (SSW) #175, was originally hired as a Certified Nursing Assistant (CNA) on 02/26/25 and later promoted to the SSW position on 10/27/25. Further review of this employee’s file confirmed that she did not hold a social work license. During an interview on 04/08/2026 at 3:23 P.M., the Administrator acknowledged that the facility was required to have a full-time qualified LSW and confirmed that SSW #175 was not licensed as a social worker and that the facility did not have any LSW employed at the time of the survey.
Facility Lacks Licensed Social Worker for Resident Services
Penalty
Summary
The facility failed to employ a Licensed Social Worker (LSW) to provide services to its residents, despite having a census of 135 residents, which exceeds the threshold of 120 beds requiring a full-time social worker. Observations revealed that a Social Work Consultant (SWC) was providing services, but there was no information posted regarding her license to practice as a social worker. Interviews with the Administrator and the SWC confirmed that the SWC had a bachelor's degree but was not a licensed social worker. The Administrator admitted to mistakenly believing the SWC was licensed and only discovered the lack of licensure upon requesting her credentials. This deficiency was identified during the investigation of Complaint Numbers OH00163464 and OH00163460.
Lack of Supervised Experience for Social Worker
Penalty
Summary
The facility failed to ensure that the social worker hired for a facility with 126 beds had the proper qualifications, specifically one year of supervised social work experience in a healthcare setting. The personnel file for the social worker, who held a Master's in Social Work, did not provide evidence of the required supervised experience. Although a reference check from a previous LTC facility was included, it did not confirm whether the social worker was supervised during her tenure there. Interviews with the Administrator, Social Service Liaison, and Director of Nursing confirmed the lack of evidence regarding the social worker's supervised experience prior to her employment at the facility. This deficiency had the potential to affect all 115 residents residing in the facility.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker, which is a requirement for facilities with more than 120 beds. This deficiency had the potential to affect all 116 residents residing at the facility. The employee file review revealed that the most recent social worker was hired on September 18, 2024, and terminated on December 19, 2024. An interview with the Administrator confirmed that the facility did not have a qualified social worker available for the residents. The Administrator mistakenly believed that the facility was only licensed for 119 beds.
Facility Lacks Qualified Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker, which is a requirement for facilities with more than 120 beds. This deficiency potentially affected all 139 residents in the facility. The Social Service Director, hired on July 22, 2022, held a bachelor's degree in business administration, not in social work or a human services field as required. The last licensed social worker was employed from September 23, 2024, to December 6, 2024, but was no longer with the facility. Interviews with the Social Service Director and the Administrator confirmed the absence of a licensed social worker at the time of the survey. This deficiency was identified during a complaint investigation.
Facility Lacks Qualified Social Worker for Over 120 Beds
Penalty
Summary
The facility failed to ensure a qualified social worker was on staff, despite having over 120 certified beds, which is a requirement. The deficiency was identified through a review of Resident Council meeting minutes, staff interviews, and examination of the Social Services Designee (SSD) #320's credentials and work history. SSD #320, who was introduced as the facility's new social worker, had a Master's degree in Social Work but had not passed the State licensing board exam and was not a licensed social worker at the time of the survey. SSD #320 confirmed she would not retake the exam until January 2025 and had not been supervised by a licensed social worker in her previous roles. The facility's job description for the Director of Social Services required a minimum of a Bachelor's Degree in Social Work, two years of supervisory experience in a medical facility, and registration as an Academy of Certified Social Workers (ACSW) member in good standing with the National Association of Social Workers (NASW). However, SSD #320's resume did not indicate she met these requirements. The Administrator acknowledged hiring SSD #320 with the knowledge that she had not yet obtained a social work license, expecting her to pass the exam in the summer of 2024, which she did not. This oversight had the potential to affect all 109 residents in the facility.
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