Failure to Conduct Required PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a significant mental illness was referred for a Level II Preadmission Screening and Resident Review (PASRR), as required by federal regulations. Resident #66, who had diagnoses including schizophrenia, hallucinations, and delusional disorder, exhibited a change in behavior that necessitated medication intervention. Despite these changes, there was no documentation of a new Level I screen or a Level II referral being initiated, which is a requirement when a resident is newly diagnosed with a mental illness or experiences a significant change in condition. The resident's comprehensive care plan documented ongoing issues with psychosis, delusions, and non-compliance with care and medications. The resident had a history of being verbally and physically violent towards staff, making accusations of abuse, and exhibiting behaviors such as throwing objects and refusing medications. Despite these significant behavioral changes, the facility did not complete the necessary PASRR evaluations to determine the specialized services required by the resident. Interviews with facility staff revealed a lack of awareness and adherence to the PASRR requirements. The Administrator admitted that the facility did not have a policy regarding PASRR, and the Director of Social Work was identified as responsible for maintaining and updating PASRR documentation. A social worker from a sister facility noted that the resident's significant change in mental illness should have prompted a new screen, highlighting a gap in the facility's compliance with federal requirements.
Plan Of Correction
Plan of Correction: Approved February 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Identified resident #66 will be screened and referred for a level II PASARR. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A 100% audit of all current residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions will be referred for a level II PASARR. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Education will be provided to the Director of Admissions and Social Work department on level II PASARR requirements. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? A monthly audit of all admissions and newly diagnosed serious mental disorders will be completed to ensure level II PASARR is completed. Audit results will be reported to QAPI monthly. The date for correction and the title of the person responsible for correction of each deficiency: Director of Social Work.