Failure to Complete PASRR for Residents Initiated on Hospice Services
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, depression, anxiety, and later bipolar disorder did not have a Level II PASRR request submitted to NC MUST when the serious mental illness diagnosis was added. The record showed antidepressant and anxiolytic orders, an MDS noting bipolar disorder and no Level II PASRR evaluation, and staff stated the DPD missed the diagnosis and delayed submitting the FL-2 and PASRR request until much later.
PASRR assessments were not updated for two residents after new mental health diagnoses were documented. One resident had records showing brief psychotic disorder, major depressive disorder, and later delusional disorder, with psychotropic orders for quetiapine and trazodone, while the PASRR did not reflect mental illness. Another resident had documented depression and anxiety, later behavioral health notes identifying major depressive disorder and decline-related concerns, and an escitalopram order for depression, but the PASRR also did not reflect mental illness.
Failure to Refer Residents With Mental Illness for PASRR Screening: The facility did not properly coordinate PASRR assessments for residents with qualifying mental health diagnoses. A resident with bipolar disorder, a resident with schizophrenia, bipolar disorder, borderline personality disorder, and PTSD, and a resident with PTSD were not correctly referred for Level I PASRR screening, and staff acknowledged that the screenings were inaccurate or incomplete. The records also showed intact cognition for two residents and moderate cognitive impairment for one resident, along with psychotropic medication use for one resident.
A resident with bipolar disorder, schizophrenia, and psychotic symptoms was not referred for PASSR Level II review after a significant change in status. The MDS Coordinator said she received the PASSR Level-I screening but did not submit a new one, and the DON said she did not know the process to follow if the screening was inaccurate. The resident’s MDS did not include PASSR status, and the on-file Level-I screening incorrectly stated the resident did not have mental illness or dementia.
A resident with anxiety, PTSD, depression, moderately impaired cognition, and documented cognitive deficits with visual hallucinations had a PASARR I that indicated further evaluation was needed, but the clinical record lacked evidence that the PASARR Level II assessment was completed. The facility could not produce documentation that the Level II was requested or provided, and an Administrative Nurse stated social services could not find proof the assessment had been done.
A resident admitted with aphasia, hemiplegia and hemiparesis, and stimulant abuse later received new diagnoses of bipolar II disorder and anxiety disorder, but the facility did not complete a new PASRR Level I. The ADON stated the resident should have had a new PASRR when the new MH diagnoses were identified.
Missed Level II PASRR Request for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a Level II PASRR evaluation request to NC MUST for a resident with a serious mental illness. Resident #10 had been deemed Level I PASRR by the State and was admitted with diagnoses including dementia, depression, and anxiety. After a hospital stay, an updated FL-2 completed by the hospital physician added bipolar disorder to the resident’s diagnoses, and bipolar disorder was also added to the facility diagnosis list. The resident’s record showed orders for venlafaxine and buspirone for depression and anxiety, and the admission MDS coded the resident with bipolar disorder and antidepressant use, while also indicating the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness. There was no documentation that a Level II PASRR evaluation was completed when the bipolar disorder diagnosis was added. During interview, the Discharge Planning Director stated she was responsible for ensuring Level II PASRR evaluations were current and accurate, and said she missed the bipolar disorder diagnosis when it was added in 10/2025. She reported that she did not request the Level II PASRR evaluation or submit the FL-2 to NC MUST until 6/9/2026, after becoming aware of the need following a later hospital return, and uploaded clinical documents on 6/10/2026 to trigger the onsite Level II evaluation. The Administrator stated the Discharge Planning Director was responsible for submitting the requests and that the evaluation should have been done immediately when the diagnosis warranted screening.
PASRR Assessments Not Updated After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASRR assessments were updated after new mental health diagnoses were documented for two residents. For one resident, the admission record showed diagnoses including brief psychotic disorder and major depressive disorder, while the Florida AHCA PASRR dated 11/11/2025 did not document mental illness. Subsequent records included physician orders for quetiapine for brief psychosis and trazodone for insomnia related to depression, along with psychology notes listing adjustment disorder, major depressive disorder, and delusional disorders. The DON stated in interview that the resident was being monitored in March because he was having a hard time after learning his cancer had returned. For the second resident, the admission record showed diagnoses including major depressive disorder and anxiety disorder, but the Florida AHCA PASRR dated 10/24/2025 did not document any mental illness. Later behavioral health documentation identified a past psychiatric history of depression and assessed major depressive disorder, recurrent, unspecified, and a subsequent progress note documented treatment concerns related to condition decline and limiting behaviors. A later physician order for escitalopram was written for depression with monitoring for isolation and sadness. The Social Services Assistant stated both PASRRs needed to be updated, and the DON stated psychology provides Social Services a list of residents seen and attends meetings where resident changes are discussed.
Failure to Refer Residents With Mental Illness for PASRR Screening
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for residents with newly evident or possible serious mental disorders. Survey review found that Resident #67, Resident #48, and Resident #7 were not referred for a Level I PASRR screening when they had diagnoses of mental illness, and the facility’s PASRR process did not accurately reflect their qualifying conditions. Resident #67’s record showed diagnoses of bipolar disorder and depression, with an admission MDS indicating intact cognition and a PASRR I screening that showed no evidence or indicator of mental illness. During interview, the MDS Nurse stated the PASRR screening was inaccurate and needed to be redone and submitted to the local health authority. Resident #67 stated he had carried a bipolar disorder diagnosis since discharge from the military. The ADON stated the MDS Nurse was responsible for referring residents with mental illness for Level I PASRR screening. Resident #48’s record showed diagnoses including schizophrenia unspecified, bipolar disorder, borderline personality disorder, and PTSD, along with regular antipsychotic and antidepressant use and a BIMS score of 15. His PASRR Level I screening indicated evidence of mental illness, but the MDS Coordinator/RN stated she had inaccurately coded the screening and that his diagnoses were qualifying diagnoses that should have been referred for PASRR evaluation. Resident #7’s record showed PTSD, a prior PASRR Level I screening that did not identify mental illness, and an annual MDS showing moderate cognitive impairment. The MDS Coordinator/RN stated Resident #7 should have had another PASRR Level I screening and referral to the local authority. The facility policy stated that when a PASRR is filled out incorrectly, the MDS coordinator will contact the corresponding case worker to correct the form.
Failure to Refer Resident With Mental Illness for PASSR Level II Review
Penalty
Summary
The facility failed to refer a resident with mental illness for Level II resident review after a significant change in status assessment. Resident #12’s quarterly MDS assessment documented a BIMS score of 8, indicating moderately impaired cognitive skills for daily decision making, and listed diagnoses of bipolar disorder and schizophrenia. The resident’s comprehensive care plan also identified unspecified psychosis, schizoaffective disorder, and bipolar disorder, with a note that the resident could see and hear people in her room trying to rape her. However, the MDS did not include PASSR status, and the resident’s PASSR Level-I screening on file stated that she did not have mental illness and did not have dementia. During interview, the MDS Coordinator said she received the resident’s PASSR Level-I screening and did not submit a new one. She stated she was not supposed to correct the PASSR Level-I screening and did not know the effect it could have on the resident if it was incorrect. The DON said PASSR was data entry and that she reviewed Level-I screenings to ensure they were entered correctly in SIMPLE, but she did not know the process to follow if the Level-I screening was inaccurate. The facility policy stated that the Level I screen should be reviewed at least quarterly and that the appropriate state designated agency should be contacted for any resident requiring a Level II screen upon learning of an SMI/ID diagnosis that was previously unknown or undetermined.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to coordinate care for a resident following a Preadmission Screening and Resident Review (PASARR) that indicated a Level II evaluation was needed. The resident had diagnoses of anxiety, PTSD, and depression, and the Quarterly MDS documented a BIMS score of 9, indicating moderately impaired cognition. The resident’s CAA also documented a cognitive deficit and visual hallucinations, and the care plan included interventions for family involvement, activities, social interaction, and in-room activities. The resident’s EMR contained a PASARR I dated 09/11/24 that indicated further evaluation was required, but the clinical record lacked evidence that the PASARR Level II evaluation was completed. When the facility was asked for evidence that the Level II assessment had been requested and provided, it was unable to produce documentation. On observation, the resident was seen sitting in the dining room with a smoker apron on, watching TV, and her hair was oily and stringy. The Administrative Nurse stated the social service department was unable to find documentation that the Level II PASARR assessment had been completed as indicated.
Failure to Complete PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a PASRR was completed when new mental health diagnoses were identified for Resident #4. The resident was admitted with diagnoses including aphasia, hemiplegia and hemiparesis, and stimulant abuse, and the medical record later documented new diagnoses of bipolar II disorder and anxiety disorder. Appendix PP of the State Operations Manual states that any resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition must be referred to the appropriate state-designated authority for review. During interview, the ADON stated that Resident #4 should have had a new PASRR Level I completed when the bipolar II disorder and anxiety disorder diagnoses were made.
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