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F0644
D

Failure to Refer Residents with Mental Illness for PASRR Evaluation

Jefferson, Louisiana Survey Completed on 05-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that referrals were made to the Louisiana Office of Behavioral Health's Preadmission Screening and Resident Review (PASRR) program for two residents with mental illness diagnoses. One resident was admitted with diagnoses of Major Depressive Disorder and Bipolar II Disorder, but there was no documented evidence that a PASRR Level II evaluation was completed or a referral was made to the PASRR program. Another resident developed a diagnosis of moderate, recurrent Major Depressive Disorder after admission, yet there was also no documentation of a PASRR Level II evaluation or referral for this new diagnosis. Interviews with facility staff confirmed that both residents met criteria requiring a PASRR Level II referral, either due to admission with a mental illness or the onset of a qualifying diagnosis after admission. Record reviews and staff statements indicated that these referrals were not identified or completed during routine audits or at the time of diagnosis, resulting in a failure to coordinate necessary assessments and referrals as required.

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