Failure to Provide Medically Related Social Services for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide medically related social services to a resident with an active diagnosis of Substance Use Disorder (SUD). The resident was admitted with a history of opioid and psychoactive substance abuse, PTSD, and major depressive disorder, and had recently used substances prior to admission. Despite facility policies requiring individualized treatment, assessment by a substance use clinician, and ongoing behavioral health support, the resident did not receive talk therapy services or documented substance use support prior to or after a hospitalization related to illicit drug use. The resident's care plan included interventions such as assistance with treatment programs, therapeutic discussions, and development of coping strategies, but there was no evidence that the social worker implemented these interventions. After the resident was hospitalized and tested positive for cocaine, there was no reassessment or updated care plan by the social worker, nor was the SUD counselor notified in a timely manner. The resident expressed a desire for more support and indicated that additional services were only offered after the incident. Interviews with facility staff, including the social worker, DON, SUD counselor, NP, and medical director, revealed that the SUD program was new and that roles and responsibilities were unclear. The social worker acknowledged not providing addiction support or setting up virtual addiction meetings, and the SUD counselor was unaware of the resident's drug use until several days after the event. The DON and medical director confirmed that the expected reassessment and support services were not provided following the resident's substance use incident.