Failure to Update PASRR with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that revisions were made to the PASRR (Pre-Admission Screening and Resident Review) applications to include updated mental health diagnoses for two residents. For Resident R71, the PASRR completed on July 27, 2023, only listed Mood Disorder and Major Depressive Disorder. However, the resident's clinical record later revealed additional diagnoses, including Psychosis, Psychotic disorder, Suicidal Behavior, and Psychotic disorder with Delusions, as of August 31, 2023. These updates were not reflected in the PASRR documentation. Similarly, Resident R98's PASRR, completed on June 6, 2022, noted bipolar and schizoaffective disorder, but failed to include an anxiety disorder diagnosis that was added to the resident's medical record on August 11, 2023. The facility's Social Worker confirmed that the PASRR forms for both residents should have been updated to reflect these additional mental health diagnoses, indicating a lapse in the coordination of assessments with the PASARR program.
Plan Of Correction
1. R71 and R98 PASARR Forms updated with the additional mental health diagnosis. 2. Audit of all residents to ensure that PASARRS capture mental health diagnosis. 3. Education to Social Services and Clinical Team that all mental health dx must be on PASARR and if there is an addition it must be added. 4. Random audits by the Administrator/designee of 5 residents to ensure PASARR includes all mental health dx. Once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.