Failure to Resubmit PASARR Screening for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to resubmit a Level I preadmission screening and resident review (PASARR) to the appropriate state-designated authority for a resident with a history of serious mental illness. The resident, who had diagnoses including schizoaffective disorder, anxiety disorder, and depression, was readmitted to the facility and had ongoing care needs related to these conditions, as documented in the care plan and Minimum Data Set (MDS). A letter from the California Department of Health Care Services indicated that a Level II mental health evaluation was required but could not be completed because facility staff were unresponsive to multiple communication attempts within 48 hours. The letter instructed the facility to resubmit a new Level I screening. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator, confirmed that the PASARR should have been resubmitted upon receipt of the state's notice. The ADON, who was responsible for the PASARR program, stated she had not seen the notice, and both the DON and Administrator acknowledged that the required resubmission did not occur as expected. The deficiency was identified for one of two sampled residents reviewed for PASARR compliance.