Failure to Complete Level 2 PASARR for Resident
Penalty
Summary
The facility failed to complete a Level 2 Preadmission Screening and Resident Review Process (PASARR) for a resident who was sampled for PASARR. The resident was admitted to the facility with diagnoses including Paralytic Syndrome, Bipolar Disorder, Current Episode Depressed, and Peripheral Vascular Disease. A Level 1 PASARR was conducted at the hospital prior to the resident's admission, indicating a hospital discharge exemption with an expectation of less than 30 days of nursing facility services. However, the resident's stay exceeded this period, necessitating a Level 2 PASARR, which was not completed. During a review of the Electronic Health Record (EHR), it was found that the Level 2 PASARR was missing. The Social Service Director (SSD) confirmed the absence of the Level 2 PASARR and acknowledged that it should have been completed based on the Level 1 PASARR findings. The SSD was unable to locate the Level 2 PASARR in the resident's records, indicating a lapse in the facility's compliance with the PASARR process requirements.
Plan Of Correction
The facility failed to complete a Level 2 Pre admission Screening and Resident Review Process (PASARR) for Resident #50. **Actions Taken:** 1) The Center Social Service Director submitted information for Preadmission Screening and Resident Review (PASARR) for a re-evaluation for resident #50. New PASARR for resident #50 was received on and a Level 2 was obtained. **Others Identified:** 2) A full house audit of current residents' Preadmission Screening and Resident Review (PASARR) was conducted to ensure that any resident with a new mental health diagnosis(s) had a PASARR evaluation completed and any mental health diagnosis(s) were identified on the current PASARR screen. Those residents identified that do not have an accurate PASARR evaluation on file will be resubmitted for a new PASARR screening no later than. Social Service staff and Nursing management are scheduled to attend Kepro training on PASARRs. **Measures Taken:** 3) The Administrator provided education to the Social Worker(s), Nursing management, and Admissions team on the requirements of the Preadmission Screening and Resident Review (PASARR) processing for mental and individuals with. **Ongoing Monitoring:** 4) The Social Worker(s) and Admission Director will audit each resident's PASARR Screen at the time of admission, during monthly Behavioral meetings, and quarterly thereafter to ensure accuracy. The Social Worker will report on the findings of the audits in the QAPI Meetings to ensure substantial compliance. The QAPI committee is responsible for the ongoing compliance.