Failure to Provide Required Behavioral Health Services to Residents with SMI
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with severe mental illness (SMI), as required by their PASRR Level II recommendations and care plans. Both residents had diagnoses including schizoaffective disorder and schizophrenia, and their PASRR assessments specified the need for rehabilitative supports such as life skills programs, psychotherapy, and regular meetings with mental health professionals. Despite these documented needs, the facility did not ensure that the recommended behavioral health services were consistently offered or provided. For the first resident, documentation showed only two group sessions attended over a five-month period, totaling one hour of behavioral health services. The resident was not listed as a participant in key groups such as symptom management, home and self-care, or social skills, despite being assessed as able to benefit from them. Facility staff stated that the resident refused both group and one-on-one sessions, but there was no documentation of these refusals or of efforts to offer one-on-one interventions as required by the care plan and PASRR recommendations. The second resident also had a history of SMI and substance use, with PASRR recommendations for multiple rehabilitative services and psychotherapy. This resident attended only three money management group sessions and one sexual health group session over several months, with no participation in other recommended groups. Staff confirmed that the resident refused additional groups and one-on-one sessions, but again, there was no documentation of refusals or of attempts to provide individualized behavioral health interventions. Both cases demonstrate a lack of implementation and documentation of required behavioral health services for residents with SMI.