Failure to Notify Mental Health Authority of PASARR Change in Condition
Penalty
Summary
The facility failed to notify the local state mental health authority of a significant change in condition for a resident with a mental disorder, as required by PASARR (Preadmission Screening and Resident Review) regulations. The resident was admitted with a diagnosis of schizophrenia and had a history of psychotic episodes, as well as a documented need for antipsychotic medication. Despite this, the facility's admission Minimum Data Set (MDS) assessment inaccurately indicated that the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability, even though clinical documentation and psychiatric evaluations confirmed the presence of schizophrenia. Further review of the resident's clinical record showed that the only available PASARR documentation was a form completed at a previous facility, which noted both mental illness and dementia diagnoses. There was no evidence that the facility had updated or revised this PASARR documentation or submitted a change in condition to the local mental health agency for evaluation, despite ongoing psychiatric assessments and the resident's intact cognition as indicated by the BIMS score. Interviews with facility staff, including the Social Service Director and the Administrator, confirmed that no Level II evaluation had been completed or initiated since the resident's admission. The deficiency was identified through record review and staff interviews, which revealed a lack of appropriate review and notification regarding the resident's mental health status and PASARR requirements. The facility did not provide additional PASARR documentation or evidence of compliance with notification protocols, and staff responses indicated a misunderstanding of the need for a Level II evaluation in the presence of both mental illness and dementia diagnoses.
Plan Of Correction
F 646 1.) Resident #60, new 77/78, was completed. All residents have the potential to be affected. 2.) A one-time audit was completed on all in-house residents to ensure their PASRR screening was up to date. The SW department was re-educated on PASRR screening by the Regional Clinical Nurse Consultant. 3.) System change: the MDS department will meet with SW weekly to ensure that all new admits, significant changes, and quarterly the PASRR have been reviewed and updated as needed. 4.) The Administrator/Designee will review 5 records weekly x 12 weeks then monthly x 3 months to ensure that PASRR screenings are updated. Any non-adherence will result in 1:1 education. All audits will be submitted to the QA committee for review and further recommendations. The Administrator will be responsible for ongoing sustained compliance.