Behavioral Health Services Revisions

Several of the regulations in the behavioral health services section of advanced copy of Appendix PP were revised. The revisions, including recommended actions, are summarized below.

F740 revisions include definition changes to mental disorders and substance use disorders.

• The mental disorder definition was revised to include “Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities, with a reference to the American Psychiatric Associations – DSM-5.
• The substance use disorder definition was revised to refer to substance use disorders as “SUDs” and included a statement that SUDs include a failure to meet major responsibilities at work, school, or home and adapted from the SAMHSA (Substance Abuse and Mental Health Services Administration).

The interpretative guidance revisions include:

• That behavioral health care needs, including SUD are to be addressed in the individual providers facility assessment and each provider should determine if they have the capacity, services, and staff skill sets to meet the requirements of behavioral health regulations.
• Requirements under the PASARR (Preadmission Screening and Resident Review) requirements. All residents are to be screened prior to admission for specialized services under PASARR requirements, however, if a resident doesn’t trigger a level 2 PASARR, but requires behavioral health services (such as counseling), the provider should demonstrate reasonable attempts to provide and/or arrange for such services, ensuring the type(s) of service(s) are clearly identified based on the resident’s individual assessment, care plan and include strategies to arrange these services.
• The inclusion of different activities as required by individual resident assessment and care planning for those that have mental health or SUD.
• Behavioral health contracts may be utilized in nursing homes, however, the interpretative guidance clearly outlines that a behavioral health contract interventions cannot interfere with the resident’s rights or be a limiting factor for admission to the nursing home, or a reason for a facility-initiated discharge (such as involuntary discharge for failure to follow the behavioral contract).
  • The guidance also states that a system that rewards or punishes a resident based on the behavior of the resident could meet the definition of abuse, so nursing homes should be very careful with the interventions in the behavior contract.
  • Behavior contracts must only be used for resident’s who have the capacity to understand them.
  • Behavior contracts should be treated similar to the resident’s care plan, including when the resident or their representative request changes to the contract or when interventions/contracts are no longer appropriate for the resident, they should be altered or discontinued.
• Nursing homes should identify that a resident with a SUD may be at an increased risk for leaving the nursing home.
• The interpretative guidance discusses that resident’s should be educated on the potential avenues for leaving the building including a therapeutic leave or discharge. Providers should be aware of what constitutes a facility-initiated discharge, potentially including a discharge that is AMA or against medical advice. 
• While the information is covered in detail in the admission, transfer, and discharge revisions of the RoPs, an AMA discharge may be considered a facility-initiated discharge if the resident is pressured into leaving AMA. 
• According to the RoP revisions, if a resident leaves the building without staff knowledge, regardless of cognitive status, would be considered an elopement. Note that the federal regulations don’t have provisions for reporting elopements to the state survey agency.  According to DIA in Chapter 50.7, elopements that are reportable are when a resident, who has impaired decision-making abilities, leaves the building without staff knowledge, regardless of injury. However, based on the federal regulation requirements, providers should follow elopement procedures for a resident that leaves the building without staff knowledge.  A recommendation would be to clearly document the resident’s decision-making ability at the time of elopement and include the provider’s process for determining if the resident elopement meant the criteria for reporting to DIA.  Once DIA has completed surveyor training on the revisions, LAI will notify providers if DIA has any changes to what is considered an elopement under Chapter 50.7.
• The interpretative guidance also outlines steps that providers may take if they suspect that a resident has a SUD including:
  • Increased monitoring and supervision to maintain the health and safety of the resident as well as other residents;
  • Restricted or supervised visitation, if the resident’s visitor(s) are deemed to be a danger to the resident, other residents, and/or staff.  
    • Additional guidance is included in the resident right’s revisions of the RoP, however, providers should have clear documentation of how they determined that a resident’s visitors are a danger to the resident, other residents, and/or staff, such as documentation of the resident’s altered behavior following the visit, which would lead the provider to believe that the visitor potentially brought in substances for the resident.
• Voluntary drug testing if there are concerns that suspected drug use could adversely affect the resident’s condition;
• Voluntary inspections, if there is reasonable suspicion of possession of illegal drugs, weapons, or other unauthorized items which could endanger the resident or others.
  • There is additional guidance in the resident right’s revisions of the RoPs, however, it is clearly stated in multiple areas of the revisions that nursing home staff are not to take the place of law enforcement.  If illegal substances are in plain sight, a staff member can confiscate the item, however, the resident or their responsible party must agree to allow staff to inspect their room or personal belongings.  Any illegal substances should be referred to law enforcement or if there is reasonable suspicion of possession of drugs, weapons, or other unauthorized items which could endanger the resident, other residents, and/or staff.

Schizophrenia

There are several locations in the revisions to the RoPs that schizophrenia is discussed. CMS has noted an increase prevalence in newly diagnosed schizophrenia in nursing home residents and they believe this is related to a diagnosis of schizophrenia not triggering the antipsychotic quality measure.  CMS believes that schizophrenia is being inaccurately diagnosed, including notes that it is uncommon for schizophrenia to be diagnosed after the age of 40 and must be diagnosed by a qualified practitioner, using evidence-based criteria and professional standards. If nursing home providers have concerns that practitioners are inaccurately diagnosing schizophrenia, they should refer them to the appropriate Board governing licensure such as the Board of Medicine, or the Board of Nursing. In addition, recent RAI changes, direct providers to not code schizophrenia as an active diagnosis in section I of the MDS, if they believe that it is inaccurately diagnosed.

F741 directs that nursing homes must have sufficient and competent staff to provide care to individual residents with SUD and a history of trauma, including PTSD (post-traumatic stress disorder).  Revisions include a definition of trauma and PTSD.

• The facility assessment should determine what staff competencies and sufficient numbers are required to provide care to the resident population that provider is able to serve. The revisions to the RoP include several statements that providers should not admit resident’s that they are unable to adequately provide care for.
• The interpretative guidance provides examples of activities and staff support that can be provided to a resident with mental health and/or SUDs.
• The key areas for noncompliance include an example of staff not being able to identify the signs and symptoms of substance use or meeting the needs of residents with a history of trauma.

While not addressed in the behavioral health section, other sections specifically state that providers are encouraged to have Naloxone on hand (such as in an E-kit) if resident’s have identified SUD or residents utilize opioid medications.

What Should Providers Do to Ensure Compliance?

• Review resident’s diagnosis and determine if resident’s in the current census have a history or substance use disorders (SUDs) and/or determine if a resident with a SUD would be considered for admission.
• Review the facility assessment and ensure that it outlines if you will admit a resident with a SUD, including in the staff competencies and skill set section of the facility assessment what staff requirements (including sufficient numbers) are.
• All staff should be trained on signs of substance use, including symptoms, behaviors and what to do in the event of an overdose.
• Discuss with your medical director and consultant pharmacist if naloxone should be added to your emergency drug kit and ensure staff are educated on how to administer it. You should include in your discussion with the medical director the potential for a standing order for naloxone if adding to the emergency kit.
• Ensure that your visitation policy and procedures outline what concerns may cause a visitor to have restrictions related to substance use and what restrictions may include. Note there will be additional guidance in the resident’s rights section.
• Ensure that you have a process for identifying potential trauma (including PTSD), all staff are competent on trauma-informed care, and potential traumas (including interventions) are outlined in individual resident care plans. There will be additional guidance on this in the trauma-informed care section.
• Ensure that resident’s with a diagnosis of schizophrenia are accurately diagnosed with schizophrenia and educate nurses on requirements for accurate diagnosis of schizophrenia so they are able to determine when a schizophrenia diagnosis may be questioned. This should include a higher-level management review of potential referrals to professional licensing boards.
• Ensure that a policy and procedures address and staff are knowledgeable about searching a residents property, including a requirement that the resident or representative must volunteer to a search.  Staff should be knowledgeable on procedures when illegal substances are identified, including referral to law enforcement.  This may include staff knowledge on discussing with a management staff member first, or other individual provider procedures on reporting residents to law enforcement.

LAI is pleased to offer a breakout session at our Fall Leadership Conference on the Opioid Epidemic, including education on substance use disorders. Based on revisions to the RoPs, this is a must-attend breakout session!  Register today for the Fall Leadership Conference if you’ve not done so.