Failure to Incorporate PASRR Level II Recommendations into Resident Care Plans
Penalty
Summary
The facility failed to review and revise the care plans for three out of four residents reviewed, specifically neglecting to incorporate recommendations from the PASRR Level II assessments. Clinical record reviews revealed that for each of these residents, the care plans did not include the specific specialized services and supports recommended by the PASRR Level II, despite the presence of significant mental health diagnoses such as schizophrenia, depression, anxiety, PTSD, and other related conditions. The care plans instead contained general statements about following PASRR recommendations without detailing the individualized interventions required for each resident. For one resident with severe cognitive impairment and multiple mental health diagnoses, the PASRR Level II recommended ongoing psychiatric medication management, individual therapy, rehabilitative services, and community placement supports. However, the care plan only referenced following PASRR recommendations and failed to specify these services. Another resident with normal cognitive function and a history of schizoaffective disorder, depression, and anxiety also had a care plan lacking the detailed interventions outlined in the PASRR Level II, such as psychiatric medication management, rehabilitative services, and community placement supports. The care plan included incomplete interventions and did not address the resident's specific needs as identified in the PASRR. A third resident with normal cognitive function and multiple psychiatric diagnoses similarly had a care plan that did not reflect the individualized recommendations from the PASRR Level II, including psychiatric medication management, individual therapy, and community placement supports. Staff interviews confirmed that the PASRR Level II recommendations were not fully integrated into the care plans, with staff expressing uncertainty about the requirements and acknowledging that the care plans were incomplete. Facility policies required that care plans be comprehensive, person-centered, and revised as resident conditions changed, and that PASRR Level II findings be incorporated, but these standards were not met for the residents reviewed.