Failure to Collaborate with External Mental Health Provider for Behavioral Health Services
Penalty
Summary
The facility failed to collaborate with a resident's external mental health provider to ensure necessary behavioral health services were provided. The resident, who was cognitively intact and had diagnoses including major depressive disorder, ADHD, generalized anxiety disorder, panic disorder, and PTSD, was identified as high risk and in need of psychotherapy for PTSD. The care plan specified therapy with an outside provider, but the electronic medical record did not show evidence of collaboration or receipt of therapy notes from the external provider. The director of social services confirmed there was no established process for obtaining therapy notes or collaborating with outside providers, and that such notes were rarely received unless there was a specific issue. Interviews with facility leadership indicated that it was expected for social services to review and upload therapy notes into the resident's EMR, but this was not occurring. The resident reported that while the facility assessed her for PTSD, it did not assess her specific triggers, and she confirmed she attended therapy outside the facility. A request for the facility's behavioral health policy was made but not fulfilled.