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F0644
D

Failure to Implement PASRR Level II Recommendations for Neurocognitive Evaluation

Denver, Colorado Survey Completed on 04-25-2025

Penalty

Fine: $36,86012 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to incorporate and arrange for the recommended neurocognitive evaluation for a resident with serious mental illness, as outlined in the resident's PASRR Level II Notice of Determination (NOD) from the State Mental Health Agency. The resident, a 71-year-old individual with diagnoses including dementia with mood disturbances, major depressive disorder, traumatic brain injury, and schizophrenia, was identified as requiring a neurocognitive evaluation due to a qualifying diagnosis of major depressive disorder. Despite this recommendation, the resident's care plan and physician orders did not include any reference to a neurocognitive evaluation, and there was no documentation of such an evaluation being scheduled or completed since admission. Record review further revealed that progress notes and social services documentation from the relevant period did not address the PASRR recommendations or any communication with the State Mental Health Agency regarding the delay or inability to follow through with the recommended evaluation. During interviews, the social services director confirmed awareness of the PASRR requirements and the process for arranging neurocognitive evaluations but could not provide a reason for the omission in this case.

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