Failure to Provide Behavioral Health Services and Care Planning for Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a primary diagnosis of alcohol use disorder and psychoactive substance abuse. Upon admission, the resident's diagnoses included psychoactive substance abuse, unspecified alcohol-induced disorder, generalized muscle weakness, and unsteadiness on feet. Despite these diagnoses, there was no documented evidence that the facility developed or implemented a person-centered care plan addressing the resident's behavioral health needs related to substance use. Interviews and record reviews revealed that the resident was allowed to leave the facility on pass without specific orders regarding supervision or duration, and there was no indication that behavioral health interventions or referrals to a psychologist were made. The resident's clinical records, both paper and electronic, lacked documentation of any care plan or interventions targeting the resident's alcohol use or psychoactive substance abuse. Staff interviews confirmed that no such care plan was developed or discussed in the interdisciplinary care team meetings. Facility policies required that residents with substance use disorders receive individualized care plans and behavioral health services, including monitoring for substance use and supporting efforts to prevent further use. However, these policies were not followed in this case, as evidenced by the absence of a care plan, lack of behavioral health service referrals, and insufficient documentation of interventions to address the resident's substance use and associated risks.