Failure to Notify State Agency of Resident Admission for PASARR
Penalty
Summary
The facility failed to notify the State Designated Agency when a resident with a diagnosis of schizoaffective disorder, bipolar type, was admitted. Review of the resident's records showed no documentation of a PASARR in the electronic record. The State Designated Agency confirmed that the resident had a Level II PASARR in 2022 and a review at another facility in 2024, but the review remained open because they were never informed of the resident's admission to the current facility. The Agency also noted that the new diagnosis would not alter the PASARR process unless there was suicidal behavior, as the resident already had a bipolar diagnosis. Interviews with facility staff revealed a lack of clarity regarding responsibility for notifying the State Designated Agency. The Administrator acknowledged that notification should have occurred upon admission, while the DON stated that the MDS nurse was responsible for this task. The Marketing Director, who had been in her role for four months, was unaware of her responsibility to contact the State Designated Agency and only recently learned of this duty. Additionally, the Administrator confirmed that the facility did not have a policy regarding PASARR notifications.