Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan included recommended specialized services identified by the state's Level II PASARR process. The facility's policies require the interdisciplinary team to use PASARR recommendations when developing care plans, especially for residents with mental disorders. Despite these policies, a review of the care plan for a resident with diagnoses including traumatic subdural hemorrhage and major depressive disorder revealed that the care plan did not document the resident's mental health diagnosis or the recommendations from the PASARR Level II evaluation. The PASARR Level II had identified a depressive disorder, a recent suicide attempt, and the need for further individualized evaluation for specialized services. Staff interview confirmed that the care plan was missing the required PASARR recommendations. The facility's policies on trauma-informed care and care planning both emphasize the importance of addressing mental health needs and specialized services as identified by PASARR, but these were not reflected in the resident's care plan at the time of review.