Failure to Accurately Review and Validate PASARR Documentation on Admission
Penalty
Summary
The facility failed to accurately review and validate Preadmission Screening and Resident Reviews (PASARR) for three out of five residents reviewed. Specifically, residents were admitted with diagnoses such as dementia, depression, anxiety, and obsessive-compulsive disorder, and were receiving psychotropic medications. However, their PASARR documentation did not consistently reflect these diagnoses or the need for a Level II evaluation, as required. For example, one resident's PASARR indicated no serious mental illness (SMI) despite documented depression and anxiety, while another's PASARR failed to list depression or OCD, even though both were present upon admission. Interviews with staff revealed that the admissions process involved reviewing PASARRs prior to admission, but there was no consistent verification of PASARR information against residents' actual diagnoses. Staff reported challenges in obtaining corrected PASARRs from hospitals and were not always aware when PASARRs were inaccurate. Additionally, there was confusion among staff regarding responsibility for verifying PASARR accuracy and awareness of updated PASARR processes, despite recent training. These lapses resulted in residents being admitted with incomplete or incorrect PASARR documentation.