Failure to Accurately Capture SMI in PASRR
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASRR) accurately captured an admission diagnosis of a serious mental illness (SMI). Specifically, the PASRR for a resident admitted on November 1, 2024, did not reflect their diagnosis of unspecified psychosis, which was part of their medical history. The facility's policy required participation in or completion of a Level I screen for all potential admissions to determine if the individual met the criteria for mental disorder, intellectual disability, or related condition. However, the resident's PASRR Level I Screening, dated October 15, 2024, incorrectly indicated that the resident did not have an SMI. Interviews with facility staff revealed that the PASRR process should have started on admission, and any discrepancies should have been addressed by resubmitting the PASRR to the hospital for correction. The Director of Nursing acknowledged that if a resident had an SMI diagnosis not captured by their PASRR, a new resident review should have been conducted. The deficiency was identified during a survey, prompting the facility to resubmit the PASRR on March 5, 2025, to accurately reflect the resident's diagnosis of unspecified psychosis.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The Pre-Admission Screening and Resident Review (PASRR) for Resident #64 was promptly reviewed and updated. Upon further examination, it was determined that a correction was necessary, and a revised PASRR was resubmitted on March 5, 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents within the facility have the potential to be affected by the deficient practice. Medical Records did a facility-wide audit of current residents' PASRR for accuracy on 3/21/25 and no additional deficient practice was noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A thorough audit of residents' PASRR was conducted by medical records to identify individuals who may have experienced any adverse effects on 3/21/2025, no additional issues were found. On 3/19/2025, an in-service was given by the Director of Nursing to all those involved in the PASRR screening process, including the medical records team, nursing management team, and admissions team. The purpose of this in-service was to reeducate those involved on the process and importance of PASRR screening regarding patient care and facility protocol. To ensure compliance with regulations, the facility will implement a system-wide change to improve the review process for all Pre-Admission Screening and Resident Review (PASRR) assessments. Going forward, the clinical team, including nurses, MDS, and other relevant healthcare professionals, will conduct a thorough review of the PASRR assessment upon each resident's admission to the facility. This review will verify that each resident's needs, including any mental health or specialized care requirements, are accurately identified and addressed in their individualized care plan. How the facility plans to monitor its performance to make sure that solutions are sustained: Upon admission, the admissions team will verify that a Pre-Admission Screening and Resident Review (PASRR) has been received, preferably via file exchange or, if necessary, as a paper copy. In cases where follow-up is required for file exchange completion, the clinical team will notify the hospital for review or a new PASRR. As part of the verification process, the clinical team immediately reviews the PASRR and checks for accuracy. A secondary screening will be performed before the PASRR is officially uploaded to the patient's chart by the medical records team. Additionally, the medical records department will review the PASRR for accuracy to ensure compliance with regulatory requirements. Furthermore, the unit manager will reassess any PASRRs requiring follow-up, with all follow-up actions being systematically tracked through the Interdisciplinary Plan of Care (IPOC) by medical records. To maintain accountability and ensure accuracy, the medical records department will conduct regular audits of PASRR. Additionally, when the facility does the resident review for new admits, if an inaccuracy is noted, a new PASRR/resident review assessment will be created to ensure the residents' PASRR is accurate according to their needs. This process will be monitored by and reported to our Quality Assurance and Performance Improvement (QAPI) monthly meeting. This will stay on our QAPI for 90 days and/or 3 QAPI meetings. Include dates when corrective actions will be completed: March 21st, 2025