Sage House - Expedition.

“Based on documentation review, record review, and interview, for one of one resident reviewed, who required behavioral care, the manager failed to ensure a resident's written service plan included the psychosocial interactions or behaviors for which the resident required assistance; the psychotropic medications ordered for the resident; the planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and the goals for changes in the resident's psychosocial interactions or behaviors. The deficient practice posed a risk as a service plan directs the services to be provided to a resident. Findings include: 1. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. 2. In record review, R1's medical record included an "After Visit Summary," from Honor Health hospital, (dated prior to R1's acceptance at the [Facility]), which documented "... You were treated for the following problems during your stay: Principal Problem: Aggressive Behavior, Active Problems: Bipolar disorder, current episode mixed, moderate, Type 2 diabetes mellitus without complications... CKD... Hypertension... s/ cadaver renal transplant, mood disorder..." 3. In record review, a "History and Physical," (dated prior to R1's acceptance at the [Facility]), documented "Aggressive Behavior (Patient sent from healthcare facility due to aggressive behavior. Patient also exhibiting attention seeking behavior. Facility sent for Crisis eval and new placement for patient)... Past Medical History... Bipolar disorder... Cancer... Dementia..." 4. In record review, R1's medical record included service plans dated May 28, 2024, and August 4, 2024, documented R1 had a diagnosis of Bipolar Disorder, Diabetes, and Mild Dementia, In addition, the medical record revealed R1 received administration of psychotropic medications including Haldol, Olanzapine, and Depakote. R1's written service plans did not include the following required components: -the psychosocial interactions or behaviors for which the resident required assistance; -psychotropic medications ordered for the resident; -planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and -goals for changes in the resident's psychosocial interactions or behaviors. 5. During an interview, E1 reported R1 received psychiatric services, and participated in a telehealth visit with the Psychiatrist on June 1, 2024, and June 28, 2024. E1 reported R1 exhibited behaviors at the facility, including cussing, fighting the staff, refusing meals, banging on the walls, stripping the bed and clothing off, and agitation. E1 acknowledged R1 received behavioral care and the service plan did not include the required components.”