Failure to Coordinate PASRR Assessments and Behavioral Health Services
Penalty
Summary
The facility failed to coordinate with the State-designated authority to ensure that residents with mental disorders received integrated care according to their needs, as required by the Pre-Admission Screening and Resident Review (PASRR) program. For one resident, the PASRR Level II recommendations for specialized behavioral health services were not implemented, and there were no orders or documentation of behavioral health referrals or provider evaluations. Another resident did not have a timely PASRR Level II evaluation completed despite ongoing symptoms of delusions and distressing hallucinations, and there was a lack of documented follow-up with the PASRR evaluator after an initial backlog was reported. Additionally, a third resident's PASRR Level I screening was completed incorrectly prior to admission, failing to identify a history of depression and the need for a Level II evaluation, which was only requested after the resident began exhibiting behaviors post-admission. These deficiencies were identified through observation, interviews, and record reviews, which revealed that the facility did not ensure PASRR processes were correctly and timely followed for three residents with significant mental health needs. The lack of coordination and follow-through with PASRR requirements resulted in missed opportunities for behavioral health interventions and services as indicated by the residents' assessments and diagnoses.