Failure to Implement PASARR Screening and Referral Process
Penalty
Summary
The facility failed to ensure that there was a process in place to identify and refer residents for Preadmission Screening and Resident Review (PASARR) Level II, and did not initiate a PASARR Level I submission for one of thirteen sampled residents. Specifically, a resident was admitted with diagnoses including unspecified psychosis and depression, but the PASARR Level I on file was completed years prior and did not reflect the current mental health diagnoses. The resident's active diagnoses, including psychosis and cognitive symptoms, were documented after admission, but there was no evidence that a new or updated PASARR Level I or a referral for Level II evaluation was initiated. Interviews with facility staff revealed a lack of understanding and training regarding PASARR processes. The Licensed Social Worker stated they had no responsibilities related to PASARR, and the Admissions Director admitted to not knowing what PASARR was or the required timeframes for completion. The Administrator confirmed that no staff member was overseeing PASARR procedures and acknowledged that the process was not being followed. The facility's policy required validation and tracking of PASARR Level I and referral for Level II when indicated, but this was not implemented for the resident in question.