By Malcolm Fraser, PhD, Psychology Consultant
As we continue to support facilities in delivering exceptional care, it’s essential to stay up-to-date on the most common survey findings and citations related to behavioral health and mental well-being in long-term care. In this month’s Survey Update, I’ll provide an overview of the most frequent behavioral health-related citations we’re seeing, along with actionable insights and recommendations to help ensure compliance while maintaining the highest standard of care.
Common Behavioral Health Citations in Recent Surveys
- Inadequate Behavioral Health Assessments
One of the most frequent citations I’ve encountered is the failure to conduct comprehensive behavioral health assessments upon admission or following significant changes in a resident’s condition. Without these thorough assessments, facilities may struggle to develop effective, personalized care plans that address mental health needs such as depression, anxiety, or dementia-related behaviors. - Inappropriate Use of Psychotropic Medications
The misuse of psychotropic medications, particularly antipsychotics, continues to be a major area of concern. Common citations stem from facilities not adequately justifying the use of psychotropics or failing to document non-pharmacological interventions that should precede medication. Overuse or improper prescribing can lead to severe side effects and adverse outcomes, including sedation, falls, and cognitive decline. - Failure to Address Behavioral Disturbances with Evidence-Based Approaches
Behavioral disturbances, especially in residents with dementia or cognitive impairments, often lead to citations related to improper management. Facilities must demonstrate the use of evidence-based, non-pharmacological approaches like behavioral therapies, environmental modifications, and personalized care interventions to manage and mitigate these challenges. - Inconsistent Documentation and Monitoring of Psychological Interventions
Inadequate documentation of therapeutic interventions and a lack of regular monitoring is another area where facilities commonly face citations. Surveyors emphasize the importance of documenting each resident’s progress in behavioral health treatment, including therapy sessions, changes in behavior, and the response to interventions. - Staff Training Deficiencies in Behavioral Health Care
Facilities that fail to provide adequate training for staff in recognizing and managing mental health issues and behavioral disturbances often face citations. It is vital for staff members, including those in non-clinical roles, to understand the signs of mental illness, how to interact effectively with residents, and how to de-escalate potentially volatile situations.
Insights and Recommendations for Behavioral Health Compliance
- Ensure Comprehensive Behavioral Health Assessments
At admission and whenever a resident’s condition changes, it’s essential to perform a thorough behavioral health assessment. This helps to identify any underlying mental health conditions, such as depression or anxiety, and ensures that appropriate care plans are developed. Incorporate standardized assessment tools and involve interdisciplinary teams, including psychologists, to ensure a comprehensive approach. - Use Psychotropic Medications Judiciously
Psychotropic medications should only be prescribed when there is a clear medical indication and after all non-pharmacological interventions have been explored. Regularly review medication regimens, especially for residents with dementia, and ensure that gradual dose reductions (GDRs) are attempted as appropriate. Document every step of the process and ensure that any adverse effects are noted and managed promptly. - Adopt Evidence-Based Behavioral Health Interventions
Behavioral interventions should always be the first-line approach for managing behavioral disturbances, particularly in patients with cognitive impairments. Implement interventions such as cognitive-behavioral therapy (CBT), reality orientation, and therapeutic activities. Train staff in recognizing triggers and managing challenging behaviors without resorting to medication. - Improve Documentation and Monitoring
Regular documentation is key to demonstrating compliance and ensuring the effectiveness of behavioral health interventions. Keep detailed records of therapy sessions, changes in behavior, and responses to different approaches. Schedule periodic reviews to monitor residents’ progress and make necessary adjustments to care plans. - Focus on Behavioral Health Staff Training
Invest in ongoing education and training for all staff, particularly in areas related to mental health and behavioral management. Regularly schedule workshops on topics like dementia care, behavioral de-escalation techniques, and how to recognize mental health symptoms. Provide specialized training for staff involved in managing residents with severe psychiatric conditions.
Conclusion
As the regulatory landscape evolves, maintaining compliance with behavioral health standards is crucial for ensuring the safety and well-being of residents. By addressing common behavioral health citations and implementing these recommendations, facilities can improve both their survey outcomes and the quality of care provided to residents. Behavioral Health Solutions is committed to supporting you in meeting these challenges and ensuring your facility provides the best care possible.