Failure to Provide Required Substance Abuse Services and Supports
Penalty
Summary
The facility failed to follow its own policies and procedures for providing services and supports for chemical dependence and substance abuse for two residents. One resident, a male with a history of schizophrenia, depression, suicidal ideation, and substance use disorder, was not offered substance abuse group programming despite expressing a history of substance abuse and a desire to participate. The resident reported that he was told he could not attend the group because his substance abuse history was not documented at admission, even though he later disclosed his history to staff. The care plan for this resident included individual counseling but did not address group participation, and attendance records confirmed he was not included in the substance abuse group sessions. Another resident, a female with diagnoses including epilepsy, psychotic disorders, bipolar disorder, and psychoactive substance abuse disorder, was not consistently provided with psychiatric, group, or behavioral health counseling and services as indicated by her history and care plan. Although her records documented a history of substance abuse and she was encouraged to participate in group sessions, documentation showed she only attended one group session and there was no evidence of one-to-one substance abuse counseling. Multiple staff interviews confirmed that discussions about her substance use were not consistently occurring during psychiatric or social work sessions, and her care plan interventions were not fully implemented. These failures resulted in the female resident using illicit substances within the facility, leading to an overdose that required emergent transfer to a local hospital. The facility's own policies required offering appropriate treatment and rehabilitative services to residents with substance abuse problems, but these were not consistently provided or documented for the residents in question. Staff interviews revealed gaps in communication, assessment, and follow-through regarding substance abuse history and the provision of necessary support services.