Failure to Refer Residents for PASARR After New Serious Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer residents with newly diagnosed serious mental illnesses to the appropriate state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR), as required by facility policy. Specifically, two residents were identified who received new diagnoses of serious mental illnesses—one with major depressive disorder, anxiety disorder, and bipolar disorder, and another with schizoaffective disorder. Despite these new diagnoses, there was no evidence in the medical records that the facility initiated or completed a new PASARR evaluation for either resident. Interviews with facility staff, including the Quality of Life Director, Director of Nursing, and Administrator, confirmed that the expectation was for a new PASARR to be completed when a resident received a new mental illness diagnosis. However, this process was not followed for the two residents in question, as documented in their records and confirmed by staff interviews. The deficiency was identified through record review and staff interviews, which revealed a lack of compliance with both facility policy and regulatory requirements regarding PASARR referrals for residents with new serious mental illness diagnoses.