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
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PASRR was not updated for a resident reviewed for behavioral services after a psychology evaluation documented major depressive disorder, recurrent, moderate, with symptoms of depressed mood, sleep disturbance, fatigue, and appetite changes. The DON stated the PASRR should have reflected depression and that Balance Wellbeing would update it, while the existing PASRR did not document any mental or suspect mental illness.
Failure to notify the county SMHA for a resident with new mental health diagnoses. The resident’s MDS showed bi-polar disorder, PTSD, and personality disorder, while the PAS only documented bi-polar disorder at admission. PTSD and personality disorder were added after admission, but the SSD said she only checks the PAS for level II PASARR needs and does not review for new diagnoses or know that SMHA contact may be needed for mental health services.
Failure to coordinate PASRR services and document required meetings affected three residents with IDD or related conditions. One resident with spina bifida and IDD had no documented annual PCSP meeting in the prior year, another resident with mild intellectual disabilities and mental health diagnoses had no documentation of quarterly PASRR PCSP meetings, and a third resident with IDD had no documentation of habilitation coordination or independent living skills training notes despite those services being recommended. Interviews confirmed the facility lacked a system to track the coordinator’s visits and required PASRR meeting documentation.
A resident who was PASRR positive related to IDD had a care plan calling for coordination of specialized services, but the facility did not incorporate PASRR recommendations into assessment, care planning, or transitions of care. A PCSP showed OT and PT were newly requested and agreed upon at a quarterly meeting, yet the LTC portal had no record of a specialized services request for therapy afterward. Staff interviews showed the MDS Coordinator, former MDS Coordinator, Habilitation Coordinator, and DON were unaware of or not trained on the PASRR requirements tied to the requested services.
PASRR Level II Evaluation Not Completed Timely: A resident with PTSD and GAD had a PASRR Level I screening that identified the need for a Level II eval, but the required review was not completed when the resident was admitted. The SSD acknowledged the PASRR process was not completed as required and stated the omission was later identified during a chart update.
PASRR Not Updated for New Mental Health Diagnoses: A resident with existing mental health diagnoses later developed PTSD and Major Depressive Disorder, but the facility did not update the PASRR or submit it for Level II review. The PASRR had listed anxiety, depression, and auditory hallucinations, and staff confirmed it needed to be updated after the new diagnoses were identified.
PASRR Not Updated for Resident With Depression
Penalty
Summary
The facility failed to update the State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) for one resident who was reviewed for behavioral services. The resident was admitted with diagnoses including Major Depressive Disorder, and the PASRR dated 8/28/2025 did not document any mental or suspect mental illness. A Balance Wellbeing Psychology Evaluation Note dated 5/6/2026 documented a chief complaint of depression and described the resident as having major depressive disorder, recurrent, moderate, with symptoms including decreased interest in activities, persistent depressed mood, sleep disturbances, fatigue, and changes in appetite occurring on more than half of the days. During an interview, the DON stated the resident's PASRR should have been updated to reflect depression and that Balance Wellbeing would be the ones to update it. The facility policy titled Resident Assessment-Coordination with PASARR Program states the facility coordinates assessments with the PASARR program for individuals with mental disorder, intellectual disability, or a related condition.
Failure to Notify SMHA for New Mental Health Diagnoses
Penalty
Summary
The facility failed to notify the county designated State Mental Health Authority (SMHA) for 1 of 5 residents, who had a new onset of mental illness. The resident’s comprehensive MDS assessment accepted on 4/22/26 identified diagnoses of bi-polar disorder, PTSD, and personality disorder, with cognition intact and no behaviors displayed during the assessment period. The resident’s PAS completed on 5/24/24 documented a current diagnosis of bi-polar disorder, but did not mention PTSD or personality disorder at that time. The diagnosis list showed PTSD was added on 5/28/24 and personality disorder on 6/24/25, both after admission. During interview on 7/7/26, the social service designee stated she only glances at the PAS for new admissions to determine whether a level II PASARR is required, does not check for new diagnoses after admission, and was not aware the SMHA needed to be contacted to determine whether mental health services would be required. A policy was requested, but none was provided during the survey period.
Failure to Coordinate PASRR Meetings and Document Specialized Services
Penalty
Summary
The facility failed to coordinate with the appropriate State-designated authority for residents with mental disorder, intellectual disability, or related conditions, as reflected in three resident records reviewed for PASRR assessments and services. Resident #6 had diagnoses including spina bifida and IDD, required assistance with multiple activities of daily living, and had a care plan that included specialized services such as habilitation coordination, independent living skills training, behavioral support, and specialized OT. Her PASRR records showed IDD, but the medical record did not indicate that an annual PCSP meeting occurred in 2025; the last meeting documented was 10/23/24. Resident #31 had diagnoses including mild intellectual disabilities, major depressive disorder, anxiety, and mixed obsessional thoughts and acts. Her annual MDS indicated moderate cognitive loss and that she was considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Her care plan stated she was PASRR positive for intellectual disabilities and that PASRR PCSP meetings were to be held with the LMHA and RP at least quarterly, but the EMR contained no documentation of quarterly PASRR PCSP meetings held in 2025. Resident #5 had diagnoses including intellectual disability and developmental disorder of scholastic skills, with a BIMS score of 9 indicating moderate cognitive impairment. His care plan identified him as PASRR positive for IDD and included habilitation and specialized services, and a PCSP meeting documented that habilitation coordination and independent living skills services were recommended. However, the EMR contained no documentation of habilitation coordination or independent living skills training notes. Interviews with the Habilitation Coordinator, MDS Coordinator, DON, Director of IDD Service, and Administrator confirmed there was no documentation after monthly visits, that the facility was not aware of when the coordinator visited, and that there was no system in place to monitor oversight or ensure the required annual and quarterly meetings were held.
PASRR Services Not Incorporated Into Resident Assessment and Care Planning
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR evaluation report into the assessment, care planning, and transitions of care for one resident who was PASRR positive related to IDD. The resident’s record showed diagnoses of schizoaffective disorder, bipolar type, and major depressive disorder, and a quarterly MDS assessment documented severe impairment in thinking with a BIMS score of 2. The care plan dated 10/17/2024 identified the resident as PASRR positive and included coordination of specialized services provided by the Local Authority. A PASRR Comprehensive Service Plan dated 12/10/2025 showed a quarterly meeting in which Medicaid eligibility was confirmed and OT and PT were new specialized services requested, with LA comments indicating all services were discussed and agreed upon. However, the LTC online portal had no record of a specialized services request for therapy after that meeting or any other meetings in the portal after that date. During interviews, the former MDS Coordinator, current MDS Coordinator, Habilitation Coordinator, and DON each described their roles and stated they were unaware of or not trained on the PASRR requirements related to the requested therapy services.
PASRR Level II Evaluation Not Completed Timely
Penalty
Summary
The facility failed to ensure compliance with PASRR requirements for RI #5 by not completing the required PASRR Level II Evaluation after the Level I screening identified the need for it. RI #5 was admitted with diagnoses of PTSD and Generalized Anxiety Disorder. The PASRR Level I Determination dated 11/07/2024 documented that, after QA review, the resident required a Level II Evaluation because of serious mental illness diagnoses, including PTSD and Generalized Anxiety Disorder, and also stated the resident met criteria for a categorical determination for convalescent care and could be admitted while the Level II Evaluation was completed. The Level I Determination further stated that the admitting nursing facility was required to report the admission to the OBRA PASRR Office at the time of admission to begin the Level II process and determine eligibility for specialized services. During interview, the SSD stated the Level I screening had been completed prior to admission, but the required Level II evaluation had not been completed at that time. She stated she did not recall whether the resident had been admitted under emergency admission or exempted hospital discharge, acknowledged responsibility for ensuring the PASRR process was completed, and stated the omission was identified during a chart update when the Level I PASRR screening was redone. She stated the Level II PASRR evaluation was completed later.
PASRR Not Updated for New Mental Health Diagnoses
Penalty
Summary
The Pre-admission Screening and Resident Review (PASRR) was not updated for a resident after new mental health diagnoses of Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder were identified during the stay. The resident had been admitted with mental health-related diagnoses including auditory hallucinations and anxiety disorder, and a physician determined the resident did not have decision-making capability for health care decisions. The resident’s PASRR was most recently completed by the facility and listed anxiety, depression, and auditory hallucinations under current diagnoses. After the resident later acquired PTSD and Major Depressive Disorder, the PASRR was not updated and submitted for Level II review. During interview, the NHA stated the PASRR was usually completed by either the Director of Admissions or the Director of Social Services, and both the Director of Admissions and the Director of Social Services confirmed the PASRR needed to be updated for the new diagnoses.
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