Next up on the CMSCG Blog “Ftag of the Week,” we are reviewing one of the Behavioral Health regulatory group tags, F742 Treatment/ Svc for Mental/ Psychosocial Concerns. The focus of this regulation is to ensure that a resident who, on admission, was assessed and displayed or was diagnosed with a mental or psychosocial adjustment difficulty, history of trauma and/or PTSD receives treatment and services to address this concern. The facility is responsible for helping residents achieve their highest practicable mental and psychosocial wellbeing, and therefore, must ensure residents with adjustment difficulties or a history of trauma/PTSD receive individualized, person-centered services and treatment to meet their assessed needs.
Information on Adjustment Difficulties, History of Trauma and Post-Traumatic Stress Disorder
F742 kind of reads like one big, long definition from a psychology textbook, but for those of you non-psych (or related area) students, it’s important to review. The Centers for Medicare and Medicaid Services (CMS) adapted the following information from the DSM-5 (2013) for reference:
“Mental disorder and psychosocial adjustment difficulty” – This is defined as the development of emotional and/or behavioral symptoms in response to an identifiable stressor that has not been the individual’s typical response in the past to stressors or the inability to adjust to stressors, as evidenced by chronic emotional/behavioral problems.
The State Operations Manual Appendix PP (revised 8/16/2024 – do you have the current version?) includes some information from the DSM-5 on the relationship between mental and psychosocial adjustment difficulties, trauma history and PTSD. What’s important to know:
- – Individuals with – or without – a history of trauma and/or PTSD can experience adjustment difficulties.
- – Adjustment difficulties occur within 3 months of the onset of a stressor and are characterized by distress that is out of proportion to the actual stressor. Once the stressor is alleviated, the adjustment difficulty lasts no longer than 6 more months. That said, some difficulties can be continuous or recurrent, depending on if multiple stressors are involved.
- – Trauma occurs after a traumatic or stressful event and involves psychological distress, which can vary, although it is often connected to feelings of anxiety/fear. Not everyone who experiences trauma will develop PTSD.
- – PTSD can have more variation, including severity and duration, depending on the type of stressor experienced. Symptoms may occur following exposure to one or more traumatic, life-threatening events, usually within the first three months afterwards.
- PTSD has the longest list of potential symptoms, ranging from re-experiencing the event to inability to experience pleasure to hyperarousal.
F742 – Regulatory Requirement
As indicated above, nursing homes are required to ensure that a resident who displays/ is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder receives appropriate treatment services. The treatment and services should either correct the resident’s assessed problem(s) or assist the resident with achieving his/her highest practicable mental and psychosocial well-being.
Identifying, but not taking the time to understand and care plan for these problems, is where many providers encounter issues. If a PRI or other documentation available on admission indicates a potential issue, such as the presence of a mental disorder, it behooves the IDT to dig in and do some research so that the resident’s needs can appropriately be met. In fact, the Interpretive Guidance (IG) for F742 clearly states that the resident and his/her family/ representative are part of the IDT and should be included to help implement a care plan which is person-centered and clinically appropriate.
There should be evidence of discussion and involvement in the development of the plan of care by the resident and/or representative/family, as appropriate. They can – and should – provide insight on what the history of the concern is, potential stressors, how the individual has successfully coped (or not) in the community, etc. This will help with the development of an individualized plan of care, which needs to include non-pharmacological interventions. (Hint, hint: the IG directs surveyors to F741 Sufficient/ Competent Staff – Behavioral Health Needs for more information on non-pharmacological interventions.)
The IG also states that the resident’s record should include documentation of:
- Expressions or indications of distress
- Lack of improvement or decline in resident functioning, if it occurs
- Steps taken to determine the underlying cause of the negative outcome
This is something that we often see lacking when we are conducting medical record reviews for our nursing home clients. There is often limited documentation of the resident’s expressions of distress, but they are labeled “behavioral.” Then, on further review, there is limited evidence that the facility has taken the necessary steps to provide treatment and services to address the diagnosis or condition, including developing individualized interventions. Many times, during a nursing home mock survey, CMSCG consultants find the same generic care plan for the majority of residents – straight from the EMR care plan library. The care plan, many times, does not go beyond “offer diversional activities,” which remain nameless, or “medication as per MD orders.” This doesn’t go far enough to ensure that residents have their psychosocial and emotional needs met. If you were having an adjustment difficulty or other mental or psychosocial concern, wouldn’t you expect your physician or mental health practitioner to treat your needs uniquely? Residents should be able to expect the same.
CMS Compliance Group, Inc. is a regulatory compliance and quality improvement consulting firm. To learn more about our nursing home mock survey, behavioral health consulting and other services, click here or contact us to discuss how we can work together.
