Failure to Maintain Accurate PASRR Screenings for Residents with Mental Disorders or Intellectual Disabilities
Penalty
Summary
The facility failed to maintain accurate Pre-admission Screening and Resident Review (PASRR) screenings for eight residents out of a sample of 52. In several cases, residents were admitted with mental health or intellectual disability diagnoses that were not accurately reflected in their PASRR Level I screenings. For example, one resident with diagnoses of Bipolar Disorder and Major Depressive Disorder had a PASRR that did not include these conditions, and no rescreen was performed to determine if a Level II evaluation was needed. Another resident with multiple mental health diagnoses and behavioral issues had a PASRR that did not indicate any mental illness or history of mental health services, nor did it reflect the primary diagnosis of Alzheimer's disease. Additional deficiencies were noted where residents' PASRR screenings failed to include relevant diagnoses such as cerebral palsy, depression, anxiety, and mood disorders. In some cases, the PASRR forms were outdated or incomplete, with sections left blank or failing to address significant mental health or intellectual disability conditions. For instance, one resident's PASRR did not mention a diagnosis of cerebral palsy, and another's did not address a mood disorder despite it being present in the medical record. There were also instances where the PASRR was not updated to reflect new or changed diagnoses after admission. Interviews with facility leadership confirmed that the expectation is for the interdisciplinary team to review PASRR documentation upon admission and complete a new PASRR if the information is incorrect or incomplete. The facility's policy requires accurate and timely coordination with the PASRR program, including maintaining up-to-date records and referring residents for Level II evaluations when necessary. However, the findings indicate that these procedures were not consistently followed, resulting in inaccurate or incomplete PASRR screenings for multiple residents.