Failure to Complete PASRRs for Residents with Mental and Intellectual Disabilities
Penalty
Summary
The facility failed to complete or update the Pre-admission Screening and Resident Reviews (PASRRs) for residents with mental illness and intellectual disabilities. This deficiency was identified for six residents out of 23 reviewed. The PASRR process is crucial for determining whether individuals with mental or intellectual disabilities require the level of services provided by a nursing facility and if they need specialized services. The facility's oversight in this process led to incomplete or outdated PASRR documentation for these residents. For Resident #12, the Level I PASRR was not revised to include diagnoses of major mental health conditions. Similarly, Resident #57's PASRR was left blank, and qualifying diagnoses were not submitted for consideration. Resident #66's PASRR was incomplete, and a Level II evaluation was not conducted despite qualifying diagnoses. Resident #30's PASRR was also incomplete, with no Level II evaluation submitted. Resident #73's PASRR did not document a qualifying diagnosis, and Resident #84's PASRR was incomplete, lacking a Level II evaluation for consideration of their diagnoses. The facility's policy requires that potential admissions are screened for serious mental or intellectual conditions through a Level I PASRR before admission. A positive Level I screen necessitates a Level II evaluation by the state-designated authority. The facility is responsible for ensuring these screenings are completed and updated as necessary, and for notifying the appropriate state authority when a resident experiences a significant change in their condition. However, the facility failed to adhere to these procedures, resulting in the identified deficiencies.
Plan Of Correction
A new screening was completed on or before for Resident #12, #57, #66, #30, #73, and #84 to accurately capture applicable diagnoses. For any that resulted in Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor, requested documentation has been submitted and is pending third party vendor review. Current residents have the potential to be affected. Current resident Preadmission Screening and Resident Review Forms will be reviewed by to ensure accuracy. For any inaccurate Preadmission Screening and Resident Review Form identified, a new screening will be completed and Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor if applicable. The facility process will be to review new admission Preadmission Screening and Resident Review Forms in the facility clinical meeting and submit revisions or requests for Resident Review Evaluation if applicable. Director of Nursing / Nursing Home Administrator/or Designee will educate Social Services Department staff, Nursing Administration staff, and Admissions Department Staff on Preadmission Screening and Resident Review Form accuracy, specific to ensuring that the Preadmission Screening and Resident Review Form captures applicable diagnoses referenced on the Preadmission Screening and Resident Review Form screening form. Director of Nursing / Nursing Home Administrator/ or Designee will audit 8 Preadmission Screening and Resident Review Forms per week for accuracy. For any inaccurate Preadmission Screening and Resident Review Form identified, a new screening will be completed and Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor if applicable. Results of the audits will be tracked and trended and reported to the monthly QAPI meeting until sustained compliance achieved.