Failure to Complete Required PASARR Specialized Services Evaluation
Penalty
Summary
The facility failed to ensure that a resident received specialized services as recommended by the state's Level II PASARR process. The resident was admitted with multiple diagnoses, including traumatic subdural hemorrhage and major depressive disorder, and had a documented history of depressive disorder and a recent suicide attempt. The PASARR Level I screening indicated the need for further evaluation, and the Level II screening required an individualized evaluation for specialized services by a Professional Independent Evaluator and the state's Mental Health Authority (MHA). Upon review of the resident's medical record, there was no documentation that the evaluation for specialized services by the state's MHA had been completed. Interviews with the Chief Nursing Officer (CNO) confirmed that the Mental Illness Evaluation and Determination report was not present in the resident's medical record, despite it being required. This lack of documentation and follow-through resulted in the resident not receiving the recommended specialized services.