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F0644
D

Failure to Update PASRR Following New Mental Disorder Diagnosis

Philadelphia, Pennsylvania Survey Completed on 01-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update the Pennsylvania Pre-Admission Screening Resident Review (PASRR) for a resident who was newly diagnosed with a serious mental disorder. The resident, admitted on March 4, 2021, had initial diagnoses including Acute Kidney Failure, Injury of Unspecified Body Region, and Type 2 Diabetes Mellitus. The PASRR Level I Form completed on the admission date indicated a negative screen for Serious Mental Illness, Intellectual Disability/Developmental Disability, or other related conditions, and no further evaluation was deemed necessary at that time. However, on June 4, 2021, the resident received a new diagnosis of Undifferentiated Schizophrenia, a serious mental disorder. Despite this significant change in the resident's mental health status, there was no documented evidence that the facility considered or initiated a referral for a Level II PASARR evaluation and determination. This oversight was confirmed during an interview with the Director of Social Services, indicating a failure to comply with the requirement to update the PASRR following a significant change in the resident's condition.

Plan Of Correction

R103 PASARR has been updated. Social Services staff have been educated regarding the importance of ensuring that residents who have a new schizophrenia are reevaluated for a new or updated PASARR. All residents with PASARRS have been reviewed by social services staff and all are accurate and up to date. All residents with PASARRS will be audited monthly for 3 months by social services or designee to ensure they are up to date. Results will be reported in monthly QAPI.

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