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BEHAVIORAL HEALTH SERVICES POLICYPREFACEThis facility promotes and supports a resident centered approach to care. The purpose of this policy is to define and set expectations regarding behavioral health services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, therefore an individualized approach to care is essential. This involves an interdisciplinary approach, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident’s distress or loss of abilities.POLICY???????It is the policy of the facility that each resident must receive and the facility must provide the necessary behavioral health care and services and medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment (483.20) and plan of care. The facility will provide sufficient staff to provide direct services to residents with the appropriate skills sets to provide nursing and related services. The interdisciplinary team will utilize information from the PASARR process as well as to complete a comprehensive assessment of resident needs, strengths, goals, life history and preference using the resident assessment instrument (RAI) specified by CMS.?OBJECTIVE OF THE BEHAVIORAL HEALTH POLICY AND PROCEDUREThe objective of the Behavioral Health Policy and Procedure is to provide a plan of care that is individualized to resident needs based upon the comprehensive assessment by the interdisciplinary team. This plan of care will include medically related social services to address behavioral health concerns and care planning to attain or maintain the highest practicable well-being.This facility will provide the necessary behavioral health care and services which include:Ensuring that the necessary care and services are person-centered and reflect the resident’s goals for care, while maximizing the resident’s dignity, autonomy, privacy, socialization, independence, choice, and safety; Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. Meaningful activities are those that address the resident’s customary routines, interests, preferences, etc. and enhance the resident’s well-being; Providing an environment and atmosphere that is conducive to mental and psychosocial well-being; Individualized non-pharmacological interventions will be care planned and implemented to meet behavioral health needs of the resident to stabilize and/or improve a resident’s mental, physical and psychosocial well-being.Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated. For concerns about the use of pharmacological interventions, see Pharmacy Services requirements at §483.45. CENTERS FOR MEDICAID AND MEDICARE SERVICES (CMS) - DEFINITIONS?Anxiety: Anxiety is a common reaction to stress that involves occasional worry about circumstantial events. Anxiety disorders include symptoms such as excessive fear and intense anxiety and can cause significant distress. Anxiety disorders are prevalent among older adults and may cause debilitating symptoms. The distinction between general anxiety and an anxiety disorder is subtle and can be difficult to identify. Accurate diagnosis by a qualified professional is essential. Anxiety can be triggered by loss of function, changes in relationships, relocation, or medical illness. Importantly, anxiety may also be a symptom of other disorders, such as dementia, and care must be taken to ensure that other disorders are not inadvertently misdiagnosed as an anxiety disorder (or vice versa).Behavior: Behavioral symptoms that may cause distress or are potentially harmful to the resident, or may be distressing or disruptive to facility residents, staff members or the environment. (CMS MDS 3.0 RAI Manual)Delirium: Acute confusional state.Delusion: a fixed, false belief not shared by others that the resident holds even in the face of evidence to the contrary. (CMS MDS 3.0 RAI Manual)Dementia: is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptomology and rates of progression. (Adapted from: “About Dementia.” Alzheimer’s Foundation of America. 30 Nov 2016. Accessed at: )Depression: Although people experience losses, it does not necessarily mean that they will become depressed. Depression is not a natural part of aging, however, older adults are at an increased risk. Symptoms may include fatigue, sleep and appetite disturbances, agitation, expressions of guilt, difficulty concentrating, apathy, withdrawal, and suicidal ideation. Late life depression may be harder to identify due to a resident’s cognitive impairment, loss of functional ability, the complexity of multiple chronic medical problems that compound the problem, and the loss of significant relationships and roles in their life. Depression presents differently in older adults and it is the responsibility of the facility to ensure that an accurate diagnosis is established.Hallucination: The perception of the presence of something that is not actually there. It may be auditory or visual or involve smells, tastes or touch. (CMS MDS 3.0 RAI Manual)Highest practicable physical, mental, and psychosocial well-being: is defined as the highest possible level of functioning and well-being, limited by the individual’s recognized pathology and normal aging process. Highest practicable is determined through the comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental or psychosocial needs of the individual.“Mental and psychosocial adjustment difficulty” refers to the development of emotional and/or behavioral symptoms in response to an identifiable stressor(s) that has not been the resident’s typical response to stressors in the past or an inability to adjust to stressors as evidenced by chronic emotional and/or behavioral symptoms. (Adapted from Diagnostic and Statistical Manual of Mental Disorders - Fifth edition. 2013, American Psychiatric Association.).Mental Disorder: A syndrome characterized by a clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental function.Mood – Signs and symptoms of mood distress (CMS MDS 3.0 RAI Manual) Non-pharmacological intervention: refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident’s mental, physical, and psychosocial well-being.PASARR: Preadmission Screening and Annual Resident Review: The PASARR process consists of the completion of a Level I screen per State and federal requirements as well as the review and implementation of the Level II recommendations upon admission into the facility.PHQ-9?: Patient Health Questionnaire for D0200 (Resident Mood Interview) is a validated interview that screens for symptoms of depression with a standardized severity score and rating, for the MDS 3.0 to screen for the presence or absence of specific clinical mood indicators in order to provide a rating for evidence of a depressive disorder. If the resident is not able to complete the PHQ-9? scripted interview, staff members who know the resident well should complete the Staff Assessment of Resident Mood (PHQ-9-OV?).Resident representative. For purposes of this subpart, the term resident representative means any of the following:(1) An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; (2) A person authorized by State or Federal law (including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; (3) Legal representative, as used in section 712 of the Older Americans Act; or. (4) The court-appointed guardian or conservator of a resident. (5) Nothing in this rule is intended to expand the scope of authority of any resident representative beyond that authority specifically authorized by the resident, State or Federal law, or a court of competent jurisdiction.Substance Use Disorder: A recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment such as health problems or disability. (disorders/substance-use) Treatment – refers to interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms.PROCEDURE FOR BEHAVIORAL HEALTH SERVICESPROCEDURE1. Preadmission and PASARR Process Identifying potential mood and behavior changes, support and care plan interventions is part of the assessment process as well as coordination of care. It is the policy or the facility to screen all potential admissions on an individualized basis for behavioral health needs. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. The below circumstances, while not an exhaustive list, may determine the need for a referral for a Level II Resident Review Evaluation:A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms. A resident with behavioral, psychiatric, or mood related symptoms that have not responded to ongoing treatment. A resident who experiences an improved medical condition—such that the resident’s plan of care or placement recommendations may require modifications. A resident whose significant change is physical, but with behavioral, psychiatric, or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living. A resident who indicates a preference (may be communicated verbally or through other forms of communication, including behavior) to leave the facility. A resident transferred, admitted, or readmitted to a NF following an inpatient psychiatric stay or equally intensive treatment.A resident whose condition or treatment is or will be significantly different than described in the resident’s most recent PASRR Level II evaluation and determination. (Reference MDS 3.0 RAI Manual) 2. AdmissionSocial Services will complete a Social Services Initial Assessment which includes the following areas (insert state and facility specific requirements here) AdmissionAdmitted from Admission DiagnosisPreadmission assessment findings Outline of social historyFamilialPersonalPast and Current life roles (work, family, community, religious, etc.) Decision making abilities and responsibilities Advance Directives Religious affiliation/preferencePlacement goalsDischarge PlanCognition statusCommunication patternsPsychosocial statusPersonality and preferencesRelationshipsCurrent life stressors or grief concernsCurrent Mood statusCurrent Behavior status and patternsHistory of Mental Disorder, Mental Health Treatment, Trauma or Post Trauma Stress Disorder PASARR Level II Completion (as applicable) Substance usePersonal preferencesIdentify interventions already in place. An initial care plan identifying resident mood and behavior needs will be completed and communicated to care givers. This information will be incorporated into the baseline care plan.Any mood and behavior symptoms will be documented by the interdisciplinary team while caring for the resident, as well as interventions attempted and outcome.Any indictors of depression or anxiety will be communicated to the physician for evaluation and potential need for provision of specialized services and supports dependent upon the resident’s individual needs.4. RAI ProcessThe RAI process (MDS, CAA’s and Care Planning) will be completed by the Interdisciplinary Team to determine person-centered care plan goals and approaches based upon the comprehensive assessment.a. MDS 3.0 completed including the PHQ-9b. Care Area Assessments as triggered by the MDS 3.0i. Psychosocial Well-Beingii. Mood Stateiii. Behavioral Symptomsiv. Psychotropic Medication Usev. ActivitiesBased upon the assessment findings, the interdisciplinary team will complete a comprehensive Person-Centered Care Plan including individualized mood and behavior interventions and approaches as applicable.Recognition and Management of Dementia:The facility will assess and determine individualized behavioral care plan interventions for individuals with dementia in order to be able to provide specialized services and supports.Behavioral interventions are individualized approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident’s distress or loss of abilities. Necessary care and services will be person-centered and reflect the resident’s goals, while maximizing the resident’s dignity, autonomy, privacy, socialization, independence, choice and safety. Care plan goals will be developed based upon the comprehensive assessment including input from the interdisciplinary team, resident, resident’s representative and/or family and achievable.Individualized non-pharmacological approaches to care will be care planned and implemented to address customary routines, interests, preferences and choices to enhance the resident’s well-being.5. Mood and Behavior Trackinga. Mood and Behavior tracking documentation will be completed by front line staff, based upon comprehensive assessment outcomes, to identify any mood and behavior patterns, interventions attempted and outcome of approaches.b. Mood and behavior tracking will be reviewed by the interdisciplinary team on a quarterly basis or more often as needed to determine trends and effectiveness of care plan interventions (see Behavior Tracking Policy and Procedure).c. Mood and behavior tracking will be reviewed by the charge nurse per facility policy to determine trends and effectiveness of care plan interventions (see Behavior Tracking Policy and Procedure).6. Psychotropic Medicationsa. Resident’s with orders for Psychotropic Medications will follow the guidelines as outlined in the facility Psychotropic Medication Use Policy and Procedure (Insert facility specific information here). 7. Care Coordinationa. The Interdisciplinary Team will initiate and continue care coordination for each resident by reviewing with the resident, resident representative and review of the medical record, making recommendations as applicable for:Referrals to behavior management committee or teamBehavioral health servicesPsychological evaluations and clinical evaluation based on assessmentPotential for PASARR Level II screen based upon a change of condition (See PASARR Policy and Procedure) Ongoing resident documentation of mood and behavior signs and symptoms as well as outcome of approaches8. DocumentationThe interdisciplinary team will document assessment findings, care plan approaches/interventions and behavior/mood tracking results in the medical record per facility policy. This documentation will be completed, but not limited to: (Edit and insert facility and state specific requirements below) Weekly SummaryAdmissionQuarterlyMonthly per Behavior Management Committee protocolsAs needed 9. Emergent ChangesIf resident displays behavioral health changes that are a potential danger to the safety, health or welfare of themselves or others, the interdisciplinary team will assess the resident’s current status and in conjunction with the discharge policy, make appropriate intervention or placement decisions. (see Discharge Transfer Policy and Procedure) 10. Facility Staff, Resources and Competencya. Sufficient Staff to Provide Behavioral Health Care and Services The facility will address in its facility assessment the behavioral health needs that can be met and the numbers and types of staff needed to meet these needs.b. Competency: Training and competency evaluation will be completed for all frontline staff on the care and services of residents with behavioral health needs and dementia including (but not limited to):Behavioral HealthComprehensive, Person-Centered Care PlanningResident-Centered Interventions/ApproachesNon-pharmacologic InterventionsCommunication and Interpersonal SkillsPromoting Residents’ IndependenceRespecting Residents’ RightsCaring for the Residents’ EnvironmentMental Health and Social Service NeedsCare of the Cognitively Impaired ResidentsDocumentationReportingReferences??Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities 10/04/16:?, State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities: CMS, MDS 3.0 RAI Manual: ................
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