Inaccurate PASRR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASRR) screenings for two residents prior to their admission. Resident #41 was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder. However, the initial Level I PASRR screen completed by a Licensed Clinical Social Worker at a hospital did not identify these mental illness diagnoses. A subsequent PASRR screen completed by a Registered Nurse at the facility also failed to include all necessary diagnoses, leading to an incomplete and inaccurate assessment. Resident #16 was admitted with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, and unspecified anxiety disorder. The Level I PASRR screen for this resident did not accurately reflect the presence of serious mental illness, as it marked that no diagnosis or suspicion of serious mental illness was indicated. This oversight resulted in the resident not being flagged for a Level II PASRR evaluation, which is required for individuals with serious mental illness or intellectual disabilities. Interviews with the facility's MDS Coordinator and Director of Nursing (DON) revealed that the PASRR screenings were often inaccurate when received from hospitals, and there was no existing PASRR policy at the facility. The MDS Coordinator acknowledged the need for a Level II PASRR review for Resident #16 and confirmed that the facility's PASRR processes were not being conducted accurately, as evidenced by the incorrect screenings for both residents.
Plan Of Correction
A new Preadmission Screening and Resident Review (PASRR) was completed on 3/14/25 for resident #41 to include anxiety. On Resident #16, Preadmission Screening and Resident Review (PASRR) was re-evaluated by the Minimum Data Set (MDS) Coordinator, and a Level II Preadmission Screening and Resident Review (PASRR) was requested and submitted to the Florida Preadmission Screening and Resident Review Portal. The Minimum Data Set (MDS) Coordinator received a response from the Florida Preadmission Screening and Resident Review Portal on the outcome of the Level II request for resident #16, and it was denied. The Minimum Data Set (MDS) Coordinator initiated an audit of the Level I Preadmission Screening and Resident Reviews (PASRRs) for all current residents to ensure the Level I Preadmission Screening and Resident Reviews are correct based on each individual resident. Identified corrections were addressed, and the appropriate corrections were made. In addition, as noted in the Statement of Deficiency, the Minimum Data Set (MDS) Coordinator recently participated in a Webinar by the Florida Preadmission Screening and Resident Review Portal. This educational Webinar addressed proper completion for Level II Preadmission Screening and Resident Reviews (PASRRs). The education included the need for a Level II Preadmission Screening and Resident Review (PASRR) to be submitted for a resident. Education was provided by the Minimum Data Set (MDS) Coordinator to the Admissions team and RN Management staff related to Level I and Level II Preadmission Screening and Resident Reviews. The education was completed by the Minimum Data Set Coordinator/designee. The Minimum Data Set (MDS) Coordinator/designee is auditing a minimum of three Preadmission Screening and Resident Reviews (PASRRs) each week for 12 weeks to ensure that the admission Preadmission Screening and Resident Reviews are accurate and the follow-up related to Level II Preadmission Screening and Resident Reviews (PASRRs) are completed. The Minimum Data Set (MDS) Coordinator/designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and, if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.