Failure to Conduct PASARR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to provide evidence of a Level 1 pre-screening for mental disorders or intellectual disabilities for a resident, identified as Resident R1. According to the facility's policy "Admission Criteria," all new admissions and readmissions are required to be screened for mental disorders, intellectual disabilities, or related disorders as part of the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. However, upon review of Resident R1's clinical records, there was no documented evidence that such a screening was conducted. This oversight was confirmed during an interview with the Nursing Home Administrator. Resident R1 was admitted to the facility on May 12, 2023, and was noted to be cognitively intact. The resident's Minimum Data Set (MDS) dated January 5, 2025, indicated diagnoses of post-traumatic stress disorder, schizophrenia, and depression. Additionally, the resident had physician orders for medications including Duloxetine for depression and Seroquel for bipolar disorder. Despite these significant mental health diagnoses, the facility did not have a Level 1 PASARR screen on record for Resident R1, which is a requirement for ensuring appropriate care and services are provided to residents with mental disorders or intellectual disabilities.
Plan Of Correction
NHA or designee to review PASSAR Level II screening to ensure resident is receiving appropriate care services based on criteria for MD, ID, and RD. Admission team and SW to be reeducated on PASSAR Level I requirement prior to admission. Random audit of admissions to be conducted by NHA, or designee, looking back at the past 3 months of admissions, to see if PASSAR Level I were obtained when appropriate. Weekly audit x4 weeks of admissions to be conducted by NHA or designee to review if PASSAR was obtained prior to admission when appropriate. After 4 weeks, monthly random audit to be conducted by NHA or designee to check for PASSAR's if appropriate. Findings of all above mentioned audits to be reported to QAPI.