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F0644
D

Failure to Timely Refer Residents for PASRR Assessment After New Psychiatric Diagnoses

Indianapolis, Indiana Survey Completed on 04-25-2025

Penalty

No penalty information released
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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 timely refer residents with new psychiatric diagnoses for appropriate Level 1 or Level 2 Preadmission Screening and Resident Review (PASRR) assessments. In one case, a resident with a history of dementia was newly diagnosed with schizoaffective disorder, and the clinical record showed that after the diagnosis and initiation of antipsychotic medication, there was no documentation of a Level 1 or Level 2 PASRR review being completed. The diagnosis was later included in a subsequent MDS assessment, but the referral for a Level 2 review was not made until several months after the diagnosis. In another instance, a resident with a new diagnosis of borderline personality disorder and subsequent initiation of Depakote did not have a new Level 1 PASRR screening completed following the diagnosis. The Social Services Director acknowledged that the screening had not been done and was unsure of the required timeframe for completion. The facility's policy required PASRR assessments to be updated with significant changes in mental or physical status, but this was not followed in these cases.

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