Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident #93, during a recertification survey. Resident #93, who has diagnoses including Schizophrenia, Anxiety Disorder, and Depression, expressed feelings of being down, depressed, and hopeless to the social worker. Despite a psychiatrist's recommendation for behavior therapy or counseling, these services were not offered. The resident's comprehensive assessment and plan of care required such interventions, but there was no documented evidence of a referral for these services. The facility's Consultation Policy and Procedure required that a physician approve or document disagreement with any consultant's recommendations. However, the Nurse Practitioner reviewing the psychiatrist's recommendations did not document agreement or disagreement, nor were any physician's orders for behavior therapy or counseling entered into the resident's medical record. The social worker reported the resident's mood to the nursing staff but did not document this communication or ensure follow-up for obtaining a physician's order for counseling services. Interviews with facility staff revealed a lack of communication and follow-through regarding the psychiatrist's recommendations. The social worker did not document their communication with the nursing staff, and the Director of Social Services acknowledged the need for documentation and follow-up. The Nurse Practitioner, who was a remote provider, stated they were instructed not to write physician orders, leaving the responsibility to in-house medical providers. The resident's primary physician was unaware of the psychiatrist's recommendations, and the medical director emphasized the need for documentation of agreement or disagreement with consultant recommendations. The resident expressed a desire for psychological services, which they had received in a previous group home setting.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F 740 – Behavioral Health Services** The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) Resident #93 was seen by the Psychologist on 12/18/2024 to address his feelings of hopelessness and Depression. b) The Attending Physician re-addressed the Psychiatrist’s recommendations dated 10/22/2024 by placing an order for [REDACTED]. c) Resident #93 – The assigned Social Worker addressed the Resident’s feelings of hopelessness and reports of feeling depressed by providing emotional support on 01/13/2025. d) The Social Worker who failed to provide emotional support to Resident #93 and failed to ensure the Resident received Psychology services as recommended by the Psychiatrist received educational disciplinary action on 01/13/2025. B) Identification of other Residents having the potential to be affected by the deficient practice: The Medical Director will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the past 6 months, to ensure that all recommendations made are reviewed and implemented if applicable; or that there is documented evidence if the physician disagreed with the recommendation. Any negative findings will be immediately corrected. The Director of Social Work/Designee will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the months of (MONTH) through (MONTH) 2024, to ensure that all recommendations made are reviewed and implemented if applicable by the assigned Social Worker. Any negative findings will be immediately corrected. Persons responsible: Medical Director & Director of Social Work C) Systemic Changes to ensure the deficient practice will not recur: e) The policy and procedure titled “Consultation” was reviewed and found to be in compliance. f) All onsite and offsite attending medical providers will be re-educated on the procedure of: a. Documenting their agreement with a consultant’s recommendation and implementing the physician’s order; or b. Documenting their disagreement and documenting the reason for disagreement. Person responsible: Medical Director g) All Social Workers will be re-educated on the following: a. Residents identified with signs and symptoms of Depression will receive documented emotional support and will be referred to the Psychiatrist and Psychologist for follow up. h) Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA – Monitor of the deficient practice: The Medical Director will have the responsibility of auditing 10% of Psychiatry consultations monthly to ensure there is documented evidence of the attending physician addressing any recommendations made. Any negative findings will be immediately corrected and reported to the QAPI committee. This audit will be completed monthly x 6 months. The Medical Director is responsible for the correction of this deficiency. The Director of Social Work will have the responsibility of auditing 10% of Residents scheduled weekly for care plan meeting, to ensure that any resident identified as having signs and symptoms of Depression on the MDS 3.0 is having same addressed by the unit assigned Social Worker. Any negative findings will be immediately corrected and reported to the QAPI committee. This audit will be completed weekly x 3 months, then monthly x 3 months. The Director of Social Work is responsible for the correction of this deficiency. Date of correction: 02/18/2025