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F0949
D

Failure to Provide Adequate Behavioral Health Training and Monitoring

Paoli, Indiana Survey Completed on 04-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a sufficient and competent behavioral and mental health training program for all staff, as required by the facility assessment and resident needs. The facility assessment identified a population with a range of behavioral health needs, including psychosis, impaired cognition, mental disorders, depression, bipolar disorder, schizophrenia, PTSD, anxiety, TBI, Down Syndrome, autism, Alzheimer's disease, non-Alzheimer's dementia, and behaviors requiring intervention. Despite this, in-service training records from the past year lacked documentation of education on individualized care, behavior monitoring, non-pharmacological interventions, and specific approaches for residents diagnosed with schizophrenia, PTSD, and TBI. Staff interviews confirmed a lack of training on these specific diagnoses, with CNAs unaware of certain residents' behavioral health conditions, their triggers, or appropriate interventions. Additionally, the facility's behavioral health management policy required identification, monitoring, and management of behavioral events, as well as individualized services based on resident needs. However, the absence of adequate behavioral health in-services and training led to failures in behavior monitoring and documentation in resident clinical records. Staff were not consistently informed about residents' behavioral health diagnoses or how to address them, resulting in non-compliance with the facility's own policies and regulatory requirements.

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