Failure to Provide Safe Environment and Effective Substance Abuse Program
Penalty
Summary
The facility failed to provide a safe environment free from drugs and alcohol and did not have an effective substance abuse program, as evidenced by multiple residents engaging in ongoing illicit drug and alcohol use while residing in the facility. Several residents with histories of substance use disorders, including opioid dependence, cocaine abuse, and alcohol abuse, were repeatedly found to be using illicit substances such as methamphetamine, cocaine, marijuana, and alcohol. Despite positive drug screens, observed drug paraphernalia, and admissions of ongoing use, the facility did not implement specific interventions to prevent or reduce illicit drug use, nor did it update care plans to address these issues. Staff interviews confirmed that drug access was a common problem and that the facility was not taking adequate action to address it. In one case, a resident with a history of opioid dependence and major depressive disorder tested positive for multiple illicit substances on several occasions, including methamphetamine, cocaine, and marijuana, without corresponding prescriptions. The resident's care plan lacked interventions specific to illicit drug use, and staff reported finding drug paraphernalia in the resident's room. The facility's behavioral health specialists stated that their recommendations for interventions were not implemented, and the administrator confirmed there was no policy addressing confirmed illicit substance use among residents. The facility's only response to suspected drug use was to notify the physician, as per their outdated policy. Other residents were also involved in incidents of drug use and related behaviors. Two residents sharing a room were found with an unknown visitor in possession of drugs, and one was observed performing sexual acts in exchange for substances. The facility failed to follow its own abuse and exploitation policies in response to this incident. Another resident with a history of alcohol and cocaine abuse was repeatedly found intoxicated, involved in altercations, and observed using marijuana in the facility, with no documented follow-up or interventions by staff. Interviews with staff and administrators confirmed a lack of cohesive care and policy regarding substance abuse, and that the facility had not taken effective steps to address the ongoing drug problem.