Failure to Accurately Complete PASARR Forms and Refer for Level II Evaluation
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASARR) forms were completed accurately and that timely referrals for Level II PASARR evaluations were made for residents with diagnoses of serious mental illness (SMI) or related conditions. Specifically, for three residents reviewed, there were discrepancies between the residents' documented diagnoses and the information recorded on their Level I PASARR forms. For one resident with major depressive disorder and anxiety disorder, the Level I PASARR indicated these diagnoses but did not trigger a Level II evaluation referral as required. Another resident with a diagnosis of depression had a Level I PASARR that did not mark depression in the SMI section, and no Level II referral was made. A third resident with anxiety had this diagnosis marked on the PASARR, but again, no Level II referral was indicated. Interviews with facility staff, including the Social Services Associate, Director of Nursing Services, and Administrator, confirmed that the PASARR forms were not completed in accordance with facility policy and that required referrals for Level II evaluations were not made when indicated by the residents' diagnoses. The staff acknowledged the inaccuracies and omissions in the PASARR process, which resulted in the failure to identify and refer residents with SMI or related conditions for further evaluation as required by regulation.