Incomplete Preadmission Screening for Two Residents
Penalty
Summary
The facility failed to ensure a complete preadmission screening was conducted for two residents during the recertification survey. Specifically, the SCREEN DOH-695 form was incomplete for these residents. Resident #169, who was admitted from an acute care hospital with unspecified diagnoses, had an incomplete form dated 7/25/2024, with item #21 left unanswered. Similarly, Resident #35, also admitted from an acute care hospital with unspecified diagnoses, had a form dated 01/10/2025, where items 24, 25, and 26 in the Level I Review for Possible Mental Condition/Developmental Disability (MR/DD) section were not completed. During interviews, the Director of Admissions acknowledged that the screens for all residents should be reviewed and completed prior to admission. However, upon reviewing the forms for the two residents, it was confirmed that the necessary items were not answered. The Administrator stated that the Admissions Department was responsible for reviewing the PASARR SCREEN forms before resident admission and was unaware of the incomplete forms. This oversight was identified as a deficiency under 10 NYCRR 415.11(e).
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: - Director of Admissions requested and received completed SCREEN Form DOH - 695 from the hospital of origin for Resident #169 and Resident #35. Identification of other residents having the potential to be affected was accomplished by: - Residents admitted to the nursing facility have the potential to be impacted. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Administrator or designee will in-service Admissions Staff on PASARR Policy and ensuring that complete preadmission screening is conducted by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Director of Admissions or designee will audit 50% of new admissions’ PASARR Forms. Beginning on 4/1/25 audits will be conducted weekly x4 weeks and then monthly x3 months. Findings will be reported during QAPI. Date of Completion and Person Responsible: - 4/20/25, Director of Admissions