F740 — Behavioral Health Services
Failure to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Reg cite · 42 CFR 483.40
27 surveys in corpus
9 states
What surveyors look for
- Psychosocial assessment on admission and as part of comprehensive assessment
- Care plan interventions for behavioral health issues, including non-pharmacological approaches FIRST
- Documented attempts to identify root cause (UTI, pain, hunger, medication side effect) before adding antipsychotic
- Consults with mental health professionals when indicated
Common gotchas
- Antipsychotic added without first ruling out delirium, pain, infection
- Behavioral interventions documented as 're-orient' for residents with advanced dementia who cannot be re-oriented
- PRN antianxiety meds becoming routine without dose review
- Care plan not updated after behaviors decrease or escalate
Real survey examples
From CMS-published 2567s in our corpus. Resident identifiers redacted.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident must receive and the facility must provide necessary behavioral health care and
services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure the necessary behavioral health care
services that were person-centered and reflect the resident's goals for care, while maximizing the resident's
dignity, autonomy, privacy, socialization, independence, choice, and safety were provided for one Resident
…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
hemiparesis after a stroke affecting her left side. R201 also has dementia, unspecified without behavioral
disturbance, psychotic disturbance, mood disturbance and anxiety. R201 is on psychotropic medications.
Social services progress notes dated [date] at 16:07:38 and reviewed on [date]. Writer met with
resident for 1:1 psychosocial visit regarding concerns of her behavior towards staff member. Writer spoke
with staff member, he verbalized he has no issues with the resident, and he understands her condition.
St…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
distress, specifically included in the care plan. SS1 said, that she wasn't sure of any underlying causes for
the behavior. Social services staff talk with the families and the resident about any behaviors. The Social
Services Director is the one responsible to send a referral to the Psychiatrist. Since there is not a Social
Services Director, the referral will be made by the Assistant Director of Nursing (ADON) to R201's
psychiatrist. The surveyor confirmed that once the referral is made, and evaluation complet…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident must receive and the facility must provide necessary behavioral health care and
services.
Based on observation, interview and record review, the facility failed to address a resident's symptoms of
depression and develop a care plan with interventions to recognize and treat symptoms of depression for
one of two residents (R47) reviewed for mood in the sample of 28.
Findings include:
The Facility's Behavioral Health Services Policy (undated) states, It is the policy of this facility to ensure …
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
deal with correspondence with the physicians that is the DON's job. I did not make notes. Her
depression/mood score was not addressed.
On [date] at 10:20 AM, V2 (Director of Nursing) stated I did not speak to the physician at any time during
correspondence relating to R47's mood and behavior.
On [date] at 2:26 PM, V10 (LPN) stated R47 is always in bed, never wants to get up, never wants to eat
unless her boyfriend comes in and brings her food. R47 does not participate in any activities and never
leaves her bed o…
Accepted POC examples
Real accepted-POC examples for this F-tag are not yet in the open corpus. The POC drafter above generates a structurally correct draft from CMS S&C Letter 13-21's four-question schema — edit it to fit your facility's specifics before submission.
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