Failure to Complete PASRR Documentation for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to submit required follow-up documentation for the completion of a Preadmission Screening and Resident Review (PASRR) Level I screen for one resident with diagnoses of psychotic disorder and bipolar disorder. The resident's medical record and the North Carolina Medicaid Long Term Care Facility Level (FL)2 Form both listed these mental health diagnoses. A PASRR Level I screen was initiated, and additional information was requested, including the most recent history and physical, a physician-signed FL2, psychiatric notes, and comprehensive notes. However, the facility did not provide the requested documentation, and as a result, never received a letter of determination regarding the resident's appropriate placement. The resident was admitted with a history of psychotic and bipolar disorders and was noted to have ongoing mood distress, including little interest or pleasure in activities and feelings of depression or hopelessness. The quarterly Minimum Data Set (MDS) confirmed the resident was cognitively intact but continued to experience mood symptoms. The facility administrator stated that the social worker responsible for PASRR screenings left the position, and the required follow-up was not completed, leaving the PASRR process incomplete for this resident.