F0740

D

Failure to Ensure Continuity of Behavioral Health Therapy Services

Canonsburg, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to ensure a resident received necessary behavioral health services as outlined in its Behavioral Health Services policy dated 8/27/25, which states that behavioral health services are to be provided as needed as part of an interdisciplinary, person-centered approach to care. The resident, identified as R33, was admitted on an unspecified date and had documented diagnoses including heart failure, anxiety, and depression per the MDS dated 1/14/26. The resident’s care plan noted a behavior problem involving requests for staff to purchase gift cards for an online friend and to take the resident to the store to buy gift cards, related to intellectual disability and poor safety awareness.

During an interview, the resident reported that their Legal Guardian had taken their personal cell phone a few weeks prior and that they had not had their private therapy call for two weeks. The DON confirmed that the resident had a standing private therapy call every Monday at 1:00 p.m. for as long as the DON had worked at the facility, and that the resident had missed two therapy appointments because the facility did not have the therapist’s name or phone number after the Legal Guardian took the phone for repairs and did not return it. Further interview with the DON revealed that the facility did not have the therapist’s contact information documented elsewhere and had not contacted the Legal Guardian to obtain it so that the resident’s weekly therapy calls could continue using a facility phone. The DON confirmed that the resident missed two therapy treatment calls and that the facility failed to ensure the resident received appropriate behavioral health services to maintain the highest practicable well-being.