Failure to Complete Required PASARR Level 2 Referrals for Residents with SMI or ID/DD
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Review (PASARR) process for residents with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD). Specifically, for two residents, the facility did not ensure that a required Level 2 PASARR referral was sent when a positive Level 1 PASARR was identified. In one case, a resident was admitted with a positive SMI for a mood disorder and was marked as an exempted hospital discharge for a stay of less than 30 days. However, when the resident's stay exceeded 30 days, the facility did not send out the required Level 2 evaluation, as confirmed by interviews with the Social Service Director, Social Service Assistant, and Director of Nursing Services. In another instance, a resident with diagnoses including depression and anxiety experienced a significant change in condition after readmission, but the facility did not complete a new Level 1 PASARR or send a referral for a Level 2 evaluation. The Social Service Director and Administrator both acknowledged that the correct process was not followed, and a new Level 1 PASARR should have been completed after the resident's change in condition. These failures were identified through record review and staff interviews, and placed the residents at risk of not receiving appropriate mental health care and services.