Failure to Provide Adequate Behavioral Health Services for Substance Use Disorders
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to residents with substance use disorders, as evidenced by multiple documented incidents involving three residents. One resident with a history of cocaine use and moderate cognitive impairment was repeatedly found smoking unknown substances, suspected to be crack cocaine, both in his room and in designated smoking areas. Staff interviews confirmed that the resident regularly smoked crack inside the facility, and paraphernalia consistent with crack cocaine use was found in his possession. Despite these findings, the only interventions implemented were education and removal of paraphernalia, with no additional behavioral health services or substance use interventions provided. Another resident, also moderately cognitively impaired, was repeatedly found in possession of and consuming alcohol within the facility. Nursing notes and staff interviews documented several occasions where alcohol was confiscated from the resident, and the resident was re-educated about facility policy and the dangers of drinking while on medication. However, the care plan interventions were limited to education and general support, with no evidence of specialized substance use disorder treatment or behavioral health services being provided. A third resident with a history of alcohol and illegal substance use, as well as multiple medical and psychiatric diagnoses, was observed drinking beer in the facility's smoking area. Staff verified the presence of alcohol, and the resident's care plan included only encouragement to express feelings and maintain contact with supportive family and friends. There was no documentation of targeted behavioral health interventions or substance use disorder treatment. The facility's policy acknowledged the risks of alcohol use but did not outline or implement comprehensive behavioral health services for residents with substance use disorders.