Failure to Provide Required Behavioral Health Services for Resident with SUD
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a diagnosis of Substance Use Disorder (SUD), opioid abuse, PTSD, and major depressive disorder. Despite the facility's policy requiring individualized treatment and ongoing behavioral health support, the resident did not receive psychiatric talk therapy or consistent follow-up from behavioral health services. The resident had consented to both medication management and talk therapy, but records show only medication management was provided, and there was no evidence of talk therapy or regular counseling sessions. After the resident was hospitalized for acute intoxication due to cocaine use, there was no documented reassessment by the SUD counselor, social worker, MD, or NP upon the resident's return. The care plan was not updated to address the recent substance use incident, and no new interventions were added. The facility's own policies required care plan updates and education following such events, but these steps were not taken. Additionally, the resident was not offered support groups such as Narcotics Anonymous (NA) or Alcoholics Anonymous (AA) upon admission or after the incident. Interviews with facility staff, including the social worker, DON, NP, SUD counselor, and medical director, confirmed that the required behavioral health services and follow-up were not provided. Staff cited reasons such as lack of time, newness of the SUD program, and unclear roles and responsibilities. The resident expressed a desire for more support and talk therapy, indicating unmet behavioral health needs during their stay.