Failure to Complete Accurate and Timely PASRR Assessments
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission for several residents with mental health diagnoses. For multiple residents, initial Level I PASRR screenings either failed to identify serious mental illness (SMI) or did not result in timely Level II referrals when indicated. In some cases, updated PASRR screenings were completed months after admission, revealing previously unrecognized SMIs and the need for Level II evaluations. Documentation showed that PASRRs were not corrected within the required timeframe, and follow-up on PASRR II referrals was not consistently performed. Specifically, residents with diagnoses such as anxiety disorder, depression, and schizophrenia were admitted without accurate or timely PASRR assessments. Staff interviews confirmed that changes in PASRR rules were not implemented promptly, and that audits and corrections were delayed due to staffing issues and lack of follow-up. As a result, residents with mental health needs were at risk of not receiving appropriate assessments and services as required by regulation.