Failure to Complete Required PASRR Level II Evaluation for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a mental disorder received a required DA-124 Level II evaluation (PASRR Level II) after a Level I screening indicated the need for further assessment. The facility's policy states that prior to admission, the DA-124 is completed, and if a Level II is triggered, the assessment should be completed and reviewed to determine if the facility can meet the resident's needs. The Level II/PASRR is then to be placed in the resident's medical record and used to develop an individualized care plan. For the resident in question, who had diagnoses of depression and schizophrenia and was receiving antidepressant and antipsychotic medications, the DA-124 Level I screening indicated a Level II was required. However, upon review, only the Level I documentation was available in the resident's record, and the Administrator confirmed that the Level II evaluation was not present. Both the Administrator and the DON acknowledged that the Level II should have been completed as required.