Incomplete Facility Assessment of Behavioral and Mental Health Needs and Resources
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a comprehensive facility assessment (FA) that accurately identified the mental and behavioral health needs of its resident population and the resources necessary to provide appropriate care. On 2/11/26, a surveyor requested and reviewed the FA dated 7/22/25, which stated its purpose was to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies. The FA’s scope referenced resident population characteristics, including physical and behavioral health needs, and required staff competencies, as well as facility resources such as behavioral health services and contracted personnel. Upon review, the FA listed certain psychiatric and mood disorders (schizophrenia, depression, anxiety) under diseases/conditions and referenced a vendor retained to provide psychiatric and psychological services, as well as behavioral and mental health services such as psychological, psychiatric, and PESS (Psychiatric Emergency Screening Services) unit. However, the FA did not identify the contracted mental health professional under Social Services, and none of the behavioral and mental health providers (psychiatrists, psychologists, licensed counselors) were named; the areas to identify these providers were left blank. Under staffing patterns for behavioral health services, the FA stated that staffing was adequate for residents with dementia, mental health conditions, or a history of trauma, but no evidence or supporting information was documented. During an interview with the LNHA, DON, and DOO, the surveyor asked them to identify where psychiatric and behavioral issues were addressed in the FA. The LNHA pointed to the sections referencing behavioral and mental health services and the contracted mental health professional but acknowledged that information for mental health providers was not available and that no evidence was listed under behavioral health staffing patterns. When asked if the FA reviewed was fully complete, the DON stated it was not, and confirmed that the facility had a large population of residents with mental health, behavioral, and psychiatric issues. Both the LNHA and DON acknowledged that several necessary components of the FA were missing, and the LNHA stated she had attempted to review the FA but had not had the chance to do so. The facility’s own policy required a comprehensive, documented facility-wide assessment addressing resident population needs, including physical and behavioral health, staffing competencies, services (including behavioral health), and shift-specific staffing, to be reviewed and updated at least annually, which was not met in this instance.
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