Failure to Complete Annual PASARR Level II Evaluations
Penalty
Summary
The facility failed to complete annual OBRA Level II PASARR (Preadmission Screen and Resident Review) evaluations for three residents who were reviewed for PASARR compliance. Specifically, the records for three residents with diagnoses including Major Depressive Disorder, Anxiety Disorder, Adjustment Disorder, Hoarding Disorder, Manic Episode, and Developmental Disorder, showed that their most recent PASARR assessments were completed in March 2024, but no updated annual assessments were found for the current year. These residents also had varying levels of cognitive impairment as indicated by their BIMS scores, with some showing severe cognitive deficits. During interviews, the facility's social worker acknowledged that some PASARR updates were missed, despite believing all necessary forms had been updated for March. The DON confirmed that the expectation is for PASARR assessments to be completed timely as per facility policy. The facility's policy requires coordination with the PASARR program and annual reviews, as well as updates upon significant changes in resident status, but this was not followed for the identified residents.