In Part 2 of our Ftag of the Week for F740 Behavioral Health Services, we’ll look at how providers are expected to determine the behavioral health needs of their residents. Last week, we discussed different types of behavioral health conditions that nursing homes may encounter in their resident population. The Centers for Medicare & Medicaid Services (CMS) expects facilities to provide behavioral health care and services that includes providing an environment that is conducive to the mental and psychosocial well-being of residents, using non-pharmacological interventions where possible, and ensuring that staff interact with residents in a manner that promotes their psychological well-being. This can be accomplished by ensuring that person-centered care and services are provided and meet the resident’s goals for care, and by ensuring that staff are adequately trained to provide the needed care.
Let’s review the Interpretive Guidance from the draft Appendix PP to understand expectations around assessments and care planning.
Identifying Residents’ Behavioral Health Needs Through Assessment
Since every resident is screened via the PASARR process to determine if specialized services are needed for a serious mental illness or intellectual disability, this gives providers a starting point for ensuring a comprehensive program is in place for each resident. However, just because a resident does not qualify for Level II services under PASARR does not mean that the resident does not need some type of behavioral health services. The services each resident needs will be identified through the comprehensive individual assessment and the care planning process. The expectation is that facilities will try to coordinate or arrange for these services. That means that attempts to coordinate counseling for a depressed resident or arrange for an Alcoholics Anonymous (AA) meeting for a resident with alcohol dependence must be attempted and documented.
Several sections of the MDS are listed in the guidance as a jumping off point:
- Section C. Cognitive Patterns
- Section D. Mood
- Section E. Behavior
- Section F. Activities
Since every resident has a comprehensive assessment, facilities can review these sections at the facility-level to help ensure they are aware of all the conditions that are present in their resident population. This information can be used to ensure staff have the appropriate training, skills and competencies to meet each resident’s behavioral health needs. It’s also a great way to update your Facility Assessment, which needs to include the behavioral needs of your resident population.
Recertification Survey Citation F740 S/S: E
A facility was cited for failure to provide necessary behavioral health care services when a resident who was prescribed an antidepressant prior to admission but was not provided one in the facility. The resident’s MDS Section D was coded to indicate symptoms of depression, and Section I was coded to indicate that the resident had depression. However, Section N was not coded to indicate that the resident received an antidepressant. On interview, the resident stated that she had told the nurse that she received an antidepressant but was not receiving it, and this was giving her nightmares.
In addition to looking globally at what services the facility’s residents need, the assessment data also helps the facility to determine the individualized approaches to care needed for each resident. The IG recommends that the Care Area Assessment (CAA) process be leveraged to assist with understanding the resident’s needs, particularly:
- Psychosocial Well-Being
- Mood State
- Behavioral Symptoms
Behavioral Health Care Planning
Once a resident’s behavioral health care needs have been identified, they need to be addressed through the development and implementation of person-centered care plans. Like any other condition that needs a care plan, individualized interventions must be in place which are reviewed and revised if they are not effective. One area where it would behoove the interdisciplinary team to spend a little extra time on is identifying potential triggers and each resident’s response to stressors so the appropriate support can be provided to the resident.
Standard/Complaint Survey Citation – F740 S/S: K
A facility was placed in Immediate Jeopardy when it failed to provide behavioral health services for residents, including conducting individualized assessments and person-centered care planning for residents who demonstrated or expressed suicidal ideation. After surveyors reviewed an incident of self-injurious behavior resulting in a hospital transfer of one resident, the records of several other residents were reviewed. Other than the initial assessments, there were no safety interventions or other behavioral health services provided to those residents, including lack of psychiatric consults.
The new emphasis on meeting behavioral health needs is reflective of the concept of person-centered care and taking the time to proactively meet a resident’s needs in this area can create a less stressful environment – for both residents and staff. Since staff are often the unintentional cause of behaviors, now is the time to re-emphasize the importance of knowing the resident and appropriate approaches for each person. With nationwide staffing issues and an increase in staff burnout, these requirements may seem like one more cumbersome thing to do, but we encourage you to think about how accurately assessing and care planning for residents’ behavioral health needs can decrease negative outcomes and help staff to be more successful caregivers. In many instances, staff do not even realize that their approach may likely cause a negative reaction with a resident – they do not realize the importance of their tone of voice, choice of words and demeanor have in caring for an individual resident with behavioral health issues.
A final note on care planning – The IG reminds surveyors that all residents should be provided with meaningful activities that address a resident’s preferences and customary routines, and the needs of residents who are living with mental health conditions or substance use disorders may differ from other residents.
Nursing homes are expected to ensure activities are in place that meet the needs of all residents. While we haven’t seen a significant number of citations at F679 Activities Meet Interest/ Needs of Each Resident in the past, the IG directs surveyors to cite F679 if they identify issues in that area. Coloring is not the activity of choice for everyone as not everyone finds it engaging.
Recertification Survey Citation F740 S/S: F
A facility was cited for failure to conduct behavioral group health therapy for residents when multiple residents told a surveyor that they wanted group therapy and were not getting it because the facility did not have the staff for it. On interview, the Social Services Director stated that all residents in the facility had some type of psychiatric condition and were supposed to be getting group therapy, but he did not have the time to do it and no one else was available to provide this type of therapy. Other facility staff were unable to provide a list of residents who were supposed to receive group therapy. The staff was obviously not on the same page regarding their responsibilities related to meeting the resident population’s needs.
The citations in this post are from recent surveys, and prior to the updated guidance to surveyors being released. These examples should be making you think potential gaps in the services you are providing in your own facility so they can be addressed. In the final part of our CMSCG Blog “Ftag of the Week” for F740, we will look at a piece of guidance that was added in the current draft guidance, Behavioral Health Contracts. It should be clear that Behavioral Health is going to be on the front burner of the surveyors visiting your facility in the very near future and it had better be on your front burner, too!
