Failure to Complete PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a PASARR Level II assessment was completed for a resident, resulting in the potential for unmet mental health care needs. The resident, a female with diagnoses including recurrent major depressive disorder, dementia with behavioral disturbances, and bipolar affective disorder, was admitted to the facility and had a BIMS score indicating severe cognitive impairment. Despite the need for a Level II assessment being identified in the initial PASARR Level I assessment, no Level II assessment was found in the resident's electronic medical record. During an interview, the social worker reported that the PASARR Level I assessment was completed, indicating the need for a Level II assessment. However, the social worker could not produce a paper copy of the Level I assessment and confirmed that there was no completed Level II assessment or recommendation letter available on the OBRA website for the resident. The absence of a PASARR Level II assessment or recommendation letter was confirmed by the survey exit.
Plan Of Correction
Element #1 Resident #16 had a completed PASARR assessment. Resident was assessed for psychosocial well-being and found to be at baseline. Care Plan and Resident Care Summary reviewed and found to be appropriate to reflect resident care needs. Element #2 Residents residing in the facility have the potential to be affected. PASARR assessments for current residents were reviewed for timely completion. Any gaps identified have been addressed. Element #3 The facility Social Workers have been re-educated to the PASARR requirements. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Administrator, or designee(s), will randomly audit residents weekly to validate timely completion of PASARR assessments. The QAPI Committee will review findings and determine ongoing need for audits. Element #5 The Administrator is responsible for sustained compliance.