Failure to Coordinate and Initiate PASRR Habilitative Therapy Services
Summary
The facility failed to coordinate with the Pre-Admission Screening and Resident Review (PASRR) program and did not initiate habilitative therapy services within the required timeframe for a resident with intellectual and developmental disabilities. Despite an interdisciplinary team (IDT) meeting where the need for specialized assessments and services in physical therapy (PT), occupational therapy (OT), and speech therapy (ST) was agreed upon, the facility did not complete or submit the necessary therapy evaluations and NFSS forms within 30 days as required. As a result, requests for these services were denied due to missing or late documentation, and the resident did not receive timely habilitative therapies as outlined in the PASRR service plan. The resident involved was an adult male with diagnoses including intellectual disabilities, Down syndrome, diabetes mellitus type II, peripheral vascular disease, and acute osteomyelitis of the right ankle and foot. At the time of the deficiency, he had moderate cognitive impairment and required assistance with all activities of daily living. He had undergone multiple surgeries resulting in the loss of all toes on his right foot, which left him unable to walk and reliant on a wheelchair for mobility. The resident expressed a desire to regain the ability to walk, but was not receiving the agreed-upon therapy services due to the facility's failure to complete the necessary PASRR processes. Interviews with facility staff revealed that there had been a change in facility ownership and staff turnover, resulting in incomplete records and a lack of continuity in care coordination. The current Director of Rehabilitation and MDS Coordinator were unable to account for the actions or documentation of previous staff, and there was no evidence that the required therapy assessments or service initiation had occurred within the mandated timeframe. Facility policy required that all specialized services identified by the Local Authority be added to the care plan and initiated within 25 days, but this was not followed in this case.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with type 2 DM, depression, mood disorders, osteomyelitis, and moderately impaired cognition had a new diagnosis of bipolar disorder type two added to the medical record, but the facility did not obtain an updated PASARR to reflect this qualifying mental health condition. The existing PASARR did not include the bipolar diagnosis, and this lack of PASARR update was confirmed by the corporate DON during surveyor interview.
A resident with multiple psychiatric diagnoses and mildly impaired cognition had Level II PASARR recommendations that were not implemented by facility staff. The PASARR outcome required 1:1 staffing due to a history of head banging and fire starting, removal of self-injurious items from reach, group therapy with a trained group therapist, a behavior management safety plan, and ongoing evaluation of psychotropic medications. Record review and interview with the staff member serving as Social Service Director confirmed that none of these interventions had been addressed or put into place, even though the resident had not displayed head banging, self-injurious behavior, or fire starting since admission.
A resident with existing diagnoses of dementia and mood disorders was given a new diagnosis of schizoaffective disorder, but staff did not update or resubmit the required PASRR Level I screening as mandated by facility policy and regulatory requirements. Interviews confirmed that staff were aware of the need for an updated PASRR following such changes, but the process was not completed.
The facility did not complete required PASRR screenings for two residents who began receiving hospice care, despite significant changes in their medical status and care needs. Both residents had complex medical histories and were dependent on staff, but no PASRR documentation was found or completed at the time hospice services were initiated.
A resident with multiple mental health diagnoses, including bipolar disorder, was not accurately represented on a PASRR Identification Screen when the assessor failed to indicate a mood disorder. The error was later discovered during a self-audit, revealing that the PASRR did not reflect all current diagnoses as required by facility policy.
A resident with multiple psychiatric diagnoses and prescribed psychotropic medications was admitted, but the PASARR only listed mood and anxiety disorders, omitting other diagnoses and all psychotropic medications. The Managed Care Coordinator confirmed these omissions, and the facility's policy requiring accurate PASARR coordination was not followed.
Failure to Update PASARR After New Bipolar Disorder Diagnosis
Penalty
Summary
Surveyors identified a deficiency in the facility’s coordination of PASARR with resident assessments and care planning when a required PASARR update was not completed after a new qualifying mental health diagnosis was added. Resident #66 was admitted on 05/14/23 with diagnoses including type 2 diabetes mellitus, depression, mood disorders, and osteomyelitis. The most recent PASARR for this resident, dated 06/08/23, did not include a diagnosis of bipolar disorder type two. The resident’s diagnosis list showed that bipolar disorder type two was added as a new mental health diagnosis on 08/20/25, and an MDS assessment dated 01/12/26 documented moderately impaired cognition. Despite this new serious mental health diagnosis, the facility did not complete a new PASARR for the resident, which was confirmed in an interview on 03/25/26 at 11:43 a.m. with the Corporate Director of Nursing, who verified that no updated PASARR had been obtained following the addition of the bipolar disorder diagnosis.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #66 on 03/26/2026. It was determined that there were no negative effects related to the missing Pre-Admission Screening & Resident Review (PASARR) identified during Annual Survey. On or before 04/30/2026, LNHA/Designee will a PASAR referral for Resident #66. The facility will ensure receipt and incorporation of PASARR findings into the resident's medical record, care plan, and service upon completion, as appropriate. LNHA notified Resident #66's primary care provider on 03/26/2026 of findings noted during Annual Survey and that no negative effects were identified during head-to-toe assessment/observation. Primary care provider acknowledged the missing Pre-Admission Screening & Resident Review (PASARR) and that there were no negative effects related to the lack of behavioral monitoring. No new orders received from primary care provider. On or before 04/30/2026, LNHA/Designee will review other residents' medical records to ensure that current residents have a Pre-Admission Screening & Resident Review (PASARR) on file. Also, on or before 04/30/2026, LNHA/Designee will evaluate list of residents and their diagnosis list(s). LNHA/Designee will evaluate diagnoses and Pre-Admission Screening & Resident Reviews (PASARR) to ensure that any diagnosis of a mental disorder and/or intellectual disability have been captured on a Pre-Admission Screening & Resident Reviews (PASARR). Any missing Pre-Admission Screening & Reviews (PASARRs) will be completed. On or before 04/30/2026, LNHA/Designee will educate Social Service Designee (SSD) in the following: 483.20(e)(2) Coordination of PASARR and Assessments §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Also, on or before 04/30/2026, LNHA/Designee will also educate Social Service Designee (SSD) that a Pre-Admission Screening & Resident Review (PASARR) is required with all new admissions and with any new mental health or intellectual disability diagnoses. LNHA/Designee will complete audits x5 residents/medical records weekly x4 weeks; then as determined by QAA. The audits will ensure that PASARR referrals are made when a resident: • Newly admits to the facility • Have a new diagnosis of serious mental illness, intellectual disability (ID), or related condition, and/or • Have had a significant change in status indicating a potential PASARR Level II trigger, and/or The audit will include: • Review of admission records • Diagnosis lists • Psychiatric consults MDS Section P Existing PASARR documentation Any resident lacking a required PASARR or with incomplete PASARR documentation will be referred immediately for PASARR review. Company policy/procedure was reviewed and no additional changes are required at this time. Education and ongoing monitoring is sufficient in ensuring regulatory compliance.
Failure to Implement Level II PASARR Recommendations
Penalty
Summary
The facility failed to ensure that Level II PASARR recommendations were implemented timely and appropriately for one resident. The resident was admitted with multiple psychiatric diagnoses, including bipolar disorder, schizoaffective disorder, personality disorder, anxiety disorder, obsessive compulsive disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder, and was assessed as having mildly impaired cognition on a quarterly MDS assessment. A Notice of PASRR Level II Outcome dated 08/25/25 specified several recommendations: 1:1 staffing due to a history of head banging and fire starting, keeping self-injurious items out of reach, provision of group therapy with a trained group therapist, development of a behavior management safety plan to decrease inappropriate behaviors and ensure safety, and ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms. Record review and staff interview showed that these PASARR recommendations were not addressed or implemented as required. The Business Office Manager, who was serving as Social Service Director at the time the Level II PASARR recommendations were issued, confirmed that the recommended 1:1 staffing, environmental controls to remove self-injurious items, group therapy, behavior management safety plan, and ongoing psychotropic medication evaluation had not been put into place. The same staff member also confirmed that the resident had not exhibited head banging, self-injurious behavior, or fire starting since admission, but the PASARR-directed interventions still had not been implemented.
Failure to Update PASRR Following New Psychiatric Diagnosis
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I was updated and resubmitted after a new diagnosis of a serious mental illness was added for one resident. Record review showed that the resident initially had diagnoses of dementia/Alzheimer's disease, mood disorder, and major depressive disorder, but later received an additional diagnosis of schizoaffective disorder. There was no evidence in the clinical record that a new or updated PASRR Level I form was completed or submitted following this new diagnosis. Interviews with the Social Services Director confirmed that a new PASRR Level I should have been completed when the psychiatric diagnosis was added, and the Administrator stated it was her expectation that the PASRR be accurate and resubmitted in such cases. The facility's policy also required PASRR updates upon significant changes in condition or new psychiatric diagnoses. Despite these expectations and policies, the required PASRR update was not performed for the resident after the new diagnosis.
Failure to Complete PASRR for Residents Initiated on Hospice Services
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASRR) for two residents who began receiving hospice services. Both residents had significant medical histories, including dementia, anxiety, and other chronic conditions, and were dependent on staff for most or all activities of daily living. Despite these changes in their care needs, there was no evidence that a PASRR was completed or updated when hospice services were initiated for either resident. Record reviews confirmed that neither resident had a PASRR completed at the time of their significant change in status, specifically when they were admitted to hospice care. This was further verified through an interview with the Social Service Designee, who acknowledged the absence of PASRR documentation for both residents during this transition. The deficiency was identified during a review of residents receiving hospice services, affecting two out of two residents reviewed in this category.
Plan Of Correction
F644 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to ensure that PASRR were completed for residents #14 and #3 regarding significant changes in condition and hospice enrollment. Step 1: Social Services promptly completed PASRRs on residents #14 and #3 for their significant change in condition. Completed on 6/12/25. Step 2: Social Services to complete an audit on all residents in the last year who have significant changes and admitted to hospice services. Completed on 6/26/25. Step 3: LNHA to provide education to IDT on process of discussing residents with significant change and possible hospice admission at morning clinical meeting, weekly resident review, and weekly PASRR meeting. Education completed by 6/30/25. Step 4: To monitor and maintain ongoing compliance, LNHA will audit PASRR weekly log and MDS Sig Changes assessments weekly x4, then monthly x2 to ensure PASRRs are being completed for residents with Sig Changes and admissions to hospice. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. --- F0657 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure residents #29 and #39 received routine care conferences. Step 2: NHA will audit the care conference schedule and compare to Comprehensive assessments and make adjustments to the care conference schedule as necessary by 6/30/25. Step 3: Social Services will be educated by LNHA on process of scheduling care conferences timely in accordance with Comprehensive assessment schedule. Education completed by 6/30/25. Step 4: Administrator will monitor compliance by auditing Care Conference completion weekly x4 weeks, then monthly x2 months. The results of the audits will be submitted to the QAPI committee for further review.
Failure to Accurately Complete PASRR Identification Screen for Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Identification Screen was completed accurately to reflect all of a resident's mental illness diagnoses. Specifically, a resident admitted with diagnoses including paranoid schizophrenia, bipolar disorder, anxiety disorder, and other specified depressive disorder had a PASRR Identification Screen completed for a significant change in condition. During this assessment, the assessor did not check the box for a mood disorder, despite the resident having a diagnosis of bipolar disorder, which qualifies as a mood disorder. This omission resulted in the PASRR not accurately reflecting the resident's mental health status at the time of the review. A subsequent self-audit by the Social Service Designee (SSD) identified the inaccuracy in the previous PASRR screen, leading to the completion of a new PASRR Identification Screen that correctly included the mood disorder diagnosis. The SSD acknowledged that audits of PASRRs were conducted every three to four months, but the inaccurate PASRR had not been identified or corrected in a timely manner. The facility's policy required accurate completion of PASRRs upon significant changes in condition, but this was not followed in this instance, resulting in the deficiency.
Failure to Accurately Complete PASARR for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) was completed accurately for a resident with multiple psychiatric diagnoses. The resident was admitted with a history of bipolar disorder, schizoaffective disorder, visual and auditory hallucinations, cognitive communication deficit, inadequate social skills, anxiety, and adult antisocial behavior. Despite these diagnoses and the use of several psychotropic medications, the PASARR completed for the resident only listed mood disorders and panic or other severe anxiety disorders, omitting other relevant diagnoses and all psychotropic medications. A review of the resident's Minimum Data Set (MDS) indicated the resident was cognitively intact, and current physician orders included multiple psychotropic medications for the management of their psychiatric conditions. During an interview, the Managed Care Coordinator confirmed that the PASARR did not include any psychotropic medications or additional diagnoses beyond mood disorder and panic or other severe anxiety disorders. The facility's policy requires coordination with the PASARR program to ensure accurate assessment and care planning for individuals with mental disorders, intellectual disabilities, or related conditions, but this was not followed in this case.
Plan Of Correction
Tag: F 0644 The facility will ensure the PASARR is completed accurately. PASARR for resident #10 has been updated by social service designee to include all diagnoses and antipsychotic medications. Social services or designee will complete a whole house audit to determine if PASARR is accurate by 6/25/25. Administrator will provide social service designee with education regarding PASARR process on 6/17/25. Administrator or designee will audit 3 PASARRs weekly for 4 weeks. Audit results will be reviewed by the QAPI committee for further recommendations.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
