Failure to Refer Residents for Level II PASRR After New Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer two residents for a Level II Preadmission Screening and Resident Review (PASRR) after they were diagnosed with new serious mental illnesses. According to facility policy, a resident review (RR) must be initiated and a Level I screening submitted in the PASRR system when there is a significant change in a resident's physical or mental condition, including new diagnoses of serious mental illness. For both residents, medical records showed new diagnoses of conditions such as bipolar disorder, anxiety disorder, psychosis, and dementia with agitation, but there was no evidence that the facility referred them to the appropriate state-designated authority for a Level II PASRR evaluation. Interviews with facility staff revealed a lack of awareness and follow-through regarding the PASRR process. The Admissions Coordinator stated that the MDS Coordinator was responsible for updating the PASRR when a new mental illness diagnosis occurred, but acknowledged that the process had not been completed. The MDS Coordinator confirmed she was unaware that a Level II PASRR was required for the affected residents. The Executive Director stated that staff were expected to revise and resubmit the PASRR to the state agency, but this had not occurred for either resident.