Is Your SNF’s Behavioral Health Program Hitting the Mark?

Is Your SNF’s Behavioral Health Program Hitting the Mark?

When it comes to running a great behavioral health program in your facility, there’s a lot to keep track of, including resident needs, staff training, documentation, compliance… the list goes on. That’s where an audit tool or checklist can be an effective way to maintain program integrity and foster continuous improvement.

Why bother with a checklist?

Behavioral health services are a critical part of resident care, especially for those dealing with depression, anxiety, dementia, or more serious mental health concerns. With so many moving parts to a successful program, things can easily slip through the cracks. A good checklist or audit tool helps your team stay compliant with regulations, ensure services are consistent and of high quality, identify areas for improvement, and support staff training and development. Simply put, it helps you keep your program running smoothly and striving for continual improvement.

What should be on your Behavioral Health Checklist?

Consider these components for inclusion in your behavioral health audit tool:

• Staff & Program Setup
  • Do you have dedicated staff serving on the behavioral health team?
  • Are credentials and licenses up to date?
  • Is there regular training on mental health and other relevant topics, such as dementia care

• Resident Screenings
  • Are residents screened for behavioral health needs on admission and regularly thereafter?
  • Are screening tools like the PHQ-2 TO 9© and BIMS being used properly?
  • Is there a clear process for referrals when residents require additional support?

• Care Planning
  • Are behavioral health needs clearly listed in the care plans?
  • Are principles of trauma informed care applied?
  • Are goals personalized and specific?
  • Is there close collaboration between behavioral health, nursing, and social services to ensure care plans are consistently updated, interventions are implemented and responses to those interventions assessed?

• Services Provided
  • Do residents receive needed interventions including, but not limited to, therapy, medication support, non-pharmacological approaches, and/or other mental health services?
  • Is progress toward care plan goals (or lack thereof) being documented?
  • Are the approaches used evidence-based and culturally sensitive?
  • Are gradual dose reductions attempted as appropriate when not clinically contraindicated?

• Documentation & Compliance
  • Are notes thorough, timely, and aligned with RAI, payor and regulatory requirements?
  • Is consent documented?
  • Is behavior tracking consistent to provide effective data for trending outcomes?
  • Does charting meet state and federal guidelines?

• Crisis Response
  • Are there clear protocols for behavioral health emergencies?
  • Are staff trained in de-escalation and suicide prevention?
  • Is there appropriate follow up on incidents that addresses root causes?

• Resident & Family Involvement
  • Are residents and families included in treatment planning?
  • Are they provided useful resources and support?
  • Are you collecting feedback regarding services and customer satisfaction?

• Ongoing Improvement
  • Is behavioral health part of your facility’s QAPI (Quality Assurance and Performance Improvement) plan?
  • Are audit results actually being used to make positive changes?
  • Are issues followed up on and tracked over time?

This type of program review doesn’t have to be a huge task, but it should be part of the QAPI program plan. Set a schedule and consider a full review quarterly or at least twice a year. Involve the whole team so everyone has a voice in the process and any necessary improvements. Track findings, and if a component of the program needs attention, build a corrective action plan and follow up accordingly. At the end of the day, an audit tool or checklist isn’t about adding more paperwork – it’s about making life easier by using a simple process that can make a big difference.

Next steps:

1. Strengthen your ability to lead positive improvements in processes and programs—register to join Proactive May 29, 2025 for a full day virtual workshop: QAPI Program Refresh
2. Save the date for Proactive’s virtual Behavioral Health Workshop coming August 26, 2025. Watch our newsletter and education page for registration details coming soon.

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