Failure to Update PASSAR Screening for Resident with New Diagnoses
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASSAR) Level I screen for a resident who had new diagnoses that could require additional mental health services. The resident was admitted with diagnoses including dementia, cognitive communication disorder, generalized anxiety disorder, and insomnia. Later, additional diagnoses such as schizophreniform disorder, persistent mood disorder, and major depressive disorder were added. Despite these changes, the facility did not conduct a new PASSAR screening after the initial one completed in August 2023. The Director of Nursing and the Regional Director of Clinical Services were unaware that the new diagnoses necessitated a new PASSAR screen, indicating a lapse in the coordination of assessments with the pre-admission screening and resident review program.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On PASSR resubmitted for resident # 62. No other deficient practice noted. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. A full house audit was completed for PASSROs needing resubmission due to new diagnosis. No other deficient practice noted. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. The DON/designee conducted education with social services and DON on ensuring request for new submission of PASSR is completed with new diagnosis meeting criteria, with an emphasis on the components of Federal regulation F644. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. The DON/Designee will conduct an audit of residents with new diagnosis meeting criteria for resubmission of PASSR to ensure compliance with federal regulation F644 weekly for 4 weeks, then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.