Failure to Complete Required PASRR Level 2 Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to provide a PASRR (Preadmission Screening and Resident Review) Level 2 evaluation for a resident whose Level 1 screening indicated the need for further assessment. The resident, who had a history of anxiety disorder and bipolar disorder, was readmitted to the facility and had a BIMS score indicating no cognitive impairment. Medical records and psychotherapy notes documented diagnoses of bipolar disorder and anxiety. However, the PASRR Level 1 screenings, including the most recent one, did not consistently reflect all current mental health diagnoses, but still indicated the need for a Level 2 evaluation. Despite this, the required PASRR Level 2 was not completed as indicated by the screening results and confirmed by the Regional Social Worker during the survey.