Failure to Provide Individualized Behavioral Health and Substance Use Services
Penalty
Summary
The facility failed to follow its own policies and procedures for behavior and substance use management by not ensuring that residents with significant histories of self-harm, suicidal behavior, and substance use received appropriate therapeutic mental health or substance abuse counseling or services. Two residents with documented histories of severe mental illness, suicidal ideation, self-harm, and substance abuse did not receive individualized care planned interventions based on the identified causes of their behaviors, preferences, or interests. The facility also did not perform timely and accurate assessments of substance abuse history to inform person-centered treatment interventions, as required by their policies. One resident, a male with diagnoses including severe bipolar disorder with psychotic features, generalized anxiety disorder, schizoaffective disorder, and substance use, was admitted following psychiatric hospitalization for suicidal ideation and self-harm. Despite recommendations for psychotherapy, group therapy, and substance abuse programming, there was no documentation of referrals to such services, participation in therapeutic groups, or individualized care plan interventions addressing his mental health and substance use needs. The resident later eloped from the facility, expressed suicidal ideation, and was transferred to the hospital, where he reported ongoing self-harm and substance use within the facility. Facility records did not show evidence of psychiatric or substance abuse counseling being offered or refused, nor were there records of activities based on his interests and preferences. Another resident with a history of depression, bipolar disorder, polysubstance use, and recent suicidal ideation also did not have a care plan with personalized interventions addressing his substance use triggers, goals for sobriety, or alternatives to substance use. Progress notes did not document any substance abuse counseling or participation in substance abuse groups for several months. Interviews with staff confirmed that specialized substance abuse counseling was not consistently available, and documentation of interventions was lacking. The facility's own policies required individualized behavioral care plans, documentation of interventions, and provision of substance use treatment services, but these were not implemented or documented for the residents reviewed.