Failure to Complete Required PASARR Re-Evaluations and Referrals
Penalty
Summary
Facility staff failed to ensure that required PASARR (Preadmission Screening and Resident Review) screenings were re-evaluated and completed as mandated for residents with indications of mental disorder or intellectual disability. For three residents reviewed, the initial Level I PASARR screens indicated the need for further evaluation (Level II PASARR) or re-screening if the stay extended beyond 30 days. However, there was no evidence in the clinical records that these follow-up screenings or referrals to the appropriate agencies were completed within the required 40-day timeframe. The deficiency was identified through medical record reviews and staff interviews, which confirmed the absence of updated PASARR documentation and necessary Level II evaluations. Specifically, one resident had a Level I PASARR screen indicating the need for a Level II evaluation, but no such evaluation was found in the records. Another resident's PASARR form also indicated the need for re-evaluation and referral, but again, no evidence of a Level II screen was present. For a third resident, the PASARR Level I form responses required a Level II evaluation, but staff acknowledged that this was not completed. These findings were corroborated by interviews with the Director of Social Services and the DON, who confirmed the lack of required follow-up PASARR documentation and evaluations.