Failure to Complete and Coordinate PASARR Level II Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to properly complete the Pre-admission Screening and Resident Review (PASARR) Level II process for residents with qualifying mental health diagnoses. Specifically, three residents were admitted with diagnoses such as Alzheimer's disease, schizoaffective disorder, bipolar disorder, and other mental health conditions, but their PASARR Level I screens did not reflect these diagnoses, and recommendations for Level II PASARR were not acted upon. Medical records and medication orders indicated the presence of serious mental illness, yet the required PASARR documentation was incomplete or inaccurate, with qualifying diagnoses left unchecked and no follow-up assessments performed as required. Interviews with the Director of Nursing (DON) confirmed that it is the facility's responsibility to review and, if necessary, resubmit PASARR assessments to ensure accuracy. The DON acknowledged that the PASARRs for the affected residents were missing necessary diagnoses and should have been corrected and updated. Additionally, the facility was unable to provide a PASARR policy when requested, further indicating a lack of proper coordination and documentation in compliance with federal requirements.
Plan Of Correction
1) Resident #8 PASARR was updated on 08/20/2025. Resident #16 PASARR was updated on 08/20/2025. Resident #17 PASARR was updated on 08/20/2025. 2) An audit of all current residents was completed on 08/20/2025 by the Director of Nursing, or designee, to verify the PASARR Level II for residents with qualifying health diagnosis. 3) Admissions team in-serviced by the Executive Director on 08/20/2025 to verify the PASARR Level II for residents with qualifying health diagnosis. Interdisciplinary team in-serviced by the Executive Director and Director of Nursing, on 08/20/2025 to verify the PASARR Level II for residents with qualifying health diagnosis. 4) The Director of Nursing, or designee, will conduct a random audit of five (5) residents per week to verify the PASARR Level II for residents with qualifying health diagnosis for four (4) consecutive weeks, then once a week for four (4) weeks, then once a month for two months, or until substantial compliance is achieved. After substantial compliance, it will be reviewed at a minimum quarterly by Director of Social Services. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee.