Delayed Coordination of Required PASRR Level 2 Evaluations
Penalty
Summary
The facility failed to ensure timely completion and coordination of required Pre-Admission Screening and Resident Review (PASRR) Level 2 evaluations for multiple residents identified as having or suspected of having Serious Mental Illness (SMI), intellectual disability, developmental disability, or related conditions. For five residents, documentation showed that although Level I PASRR screenings indicated the need for a Level 2 evaluation, there were significant delays in initiating and following up on these referrals. In several cases, no action was taken to coordinate the Level 2 evaluation until several months after the need was identified, and there was a lack of timely follow-up with the agency responsible for conducting the evaluations. Residents involved had diagnoses including anxiety disorder, depression, and bipolar disorder, and some were receiving related medications. Staff interviews confirmed that delays occurred due to workload issues and lack of assistance, and that follow-up with the PASRR agency did not occur within the expected timeframe. The records did not show evidence of prompt or consistent efforts to ensure that residents received the required person-centered evaluations prior to or shortly after admission, as mandated.