Failure to Timely Resubmit PASSR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASSR) in a timely manner after a new mental health diagnosis was added for a resident. According to the facility's policy, a referral for a PASSR Level II evaluation must occur promptly when a significant change in status, such as a new mental health diagnosis, is identified. The policy specifically states that the referral should be made as soon as the criteria are evident, without waiting for the completion of a significant change in status assessment (SCSA). Medical record review showed that the resident was initially admitted with a diagnosis of Depression and later diagnosed with Generalized Anxiety Disorder and Bipolar Disorder. Despite the addition of Bipolar Disorder as a new diagnosis, the facility did not submit a new PASSR to the state-designated authority. The resident's care plan and psychiatric notes reflected the updated diagnoses, and the administrator confirmed that the facility did not follow the expected process of resubmitting the PASSR after the new mental health diagnosis was identified.