Failure to Employ Required Psychiatric Rehabilitation Services Director
Penalty
Summary
The facility failed to employ a qualified Psychiatric Rehabilitation Services Director (PRSD) as required for its locked mental illness behavioral unit, resulting in insufficient staffing with appropriate competencies to meet residents' behavioral health needs. A resident on the locked unit, diagnosed with Borderline Personality Disorder, Suicidal Ideation, Anxiety, Bipolar Disorder, Major Recurrent Depression, Post-Traumatic Stress Disorder, Cocaine Abuse, and Nicotine Dependence, reported that staff wanted to "kick him out" and expressed a desire to speak with the Administrator for clarification. The resident’s care plans documented that he was generally independent in emotional, intellectual, physical, and social needs, usually able to perform ADLs independently or with supervision, and had a goal to return home or to the community, with interventions including evaluation for appropriate living environment, coordination with community support resources, and provision of written instructions. During the survey, the DON, a Psychiatric Rehabilitation Services Counselor (PRSC), and the Administrator each confirmed that the facility did not currently employ a PRSD and had not done so since November 2025. The Administrator stated that an LPN had attempted to fill the PRSD position but it was not a good fit, and that although the PRSC was qualified, the Administrator believed her personality was too timid for the role. The Administrator acknowledged that having a PRSD and providing community reintegration groups are state requirements for a mental illness behavioral unit. A staff member reported that the resident was not being discharged involuntarily but that the facility was not providing community reintegration groups and that these services could be provided at another nursing facility, which she believed would be more beneficial for the resident. The staff roster did not list a PRSD, and throughout the survey the mental illness unit Director’s office remained closed and unoccupied, further evidencing the absence of a functioning PRSD.
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