Failure to Complete Accurate PASARR Level I Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I Screening was properly completed for one of four sampled residents. The PASARR Level I Screening, dated 7/12/2024, indicated that the resident did not have serious mental diagnoses and did not require a Level II Screening. However, subsequent reviews of the resident's admission records, diagnosis worksheets, Minimum Data Set (MDS) assessments, and psychiatric evaluations revealed multiple mental health diagnoses, including anxiety disorder, schizophrenia, psychosis, depression, and episodes of delusions and hallucinations. The resident's admission record listed diagnoses such as anxiety disorder, schizophrenia, hemiplegia, and hemiparesis following a cerebral infarction. The MDS assessments and care plan further documented ongoing mental health issues, including anxiety disorder, depression, and psychosis. Despite these documented conditions, the initial PASARR Level I Screening did not reflect the resident's mental health status, and a Level II Screening was not initiated as required. Interviews with facility staff, including the MDS Specialist and the DON, confirmed that the PASARR Level I Screening should have been completed or updated to reflect the resident's psychiatric diagnoses. The facility's policy also indicated that a status change Level I PASARR screening should be completed if there is a change in psychiatric diagnoses or a discrepancy between PASARR and physician diagnoses. The failure to complete an accurate PASARR Level I Screening had the potential to delay necessary care and services for the resident.
Plan Of Correction
Maclay Healthcare Center makes every effort to comply with the State and Federal regulations. Nothing in this plan of correction is an admission otherwise. Maclay Healthcare Center submitted this plan of correction to comply with the State and Federal regulations and does not waive any objection obtained. This plan of correction is our credible allegation of compliance for deficiency noted findings of the California Department of Public Health during the Facility reported incidents survey completed on 3/22/25.