Failure to Refer Residents with Serious Mental Illness for Level 2 PASRR Evaluation
Penalty
Summary
The facility failed to obtain updated Pre-Admission Screening and Resident Review (PASRR) assessments for two residents who had diagnoses of significant mental illness. One resident was admitted with Alzheimer's disease, anxiety, depression, and bipolar disorder, and their Level 1 PASRR indicated serious mental illness, but no referral for a Level 2 PASRR was made. Another resident was admitted with major depressive disorder, and their Level 1 PASRR also indicated a serious mental illness, yet no Level 2 PASRR referral was placed. These findings were confirmed through interviews and record reviews, where the Social Services Director acknowledged that referrals for Level 2 PASRR evaluations should have been made according to updated regulatory guidance. The deficiency was identified through review of resident records and staff interviews, which showed that the required coordination with the PASRR program and appropriate referrals for further mental health assessment were not completed for residents with identified serious mental illness.