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F0644
D

Failure to Accurately Complete PASARR for Resident with Psychiatric Diagnoses

Lima, Ohio Survey Completed on 06-09-2025

Penalty

Fine: $52,875
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

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