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F0644
D

Failure to Complete and Refer PASARR Level II Evaluations for Residents with Mental Health Diagnoses

Warren, Michigan Survey Completed on 05-07-2025

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 ensure that required Preadmission Screening and Resident Review (PASARR) procedures were followed for two residents with mental health diagnoses. For one resident with hemiparesis, schizoaffective disorder, anxiety disorder, and major depressive disorder, a Level I PASARR screening was completed as a change of condition, but there was no evidence of a referral for a Level II evaluation or that such an evaluation was completed, despite the resident's mental health diagnoses. The social worker confirmed that the Level II evaluation was not done, and the nursing home administrator stated that PASARRs and Level II evaluations should be completed timely per policy. For another resident with major depressive disorder and generalized anxiety disorder, the PASARR Level I Change in Condition screening form was completed inaccurately, as it failed to document the resident's current mental illness diagnosis and recent use of prescribed antidepressant medication. The social worker acknowledged the form was completed incorrectly. The facility's policy requires that individuals with or suspected of having mental disorders be referred for a Level II PASARR evaluation, but this process was not followed for these residents.

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