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F0644
D

Failure to Complete PASARR Level II Assessment for Resident with Mental Health Diagnosis

Prescott, Arizona Survey Completed on 07-25-2025

Penalty

No penalty information released
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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 a PASARR Level II assessment was completed in a timely manner for one resident who was admitted with a diagnosis of bipolar disorder, current episode depressed, mild or moderate severity. Documentation showed that the resident's Minimum Data Set (MDS) indicated intact cognitive function and confirmed the diagnosis of bipolar disorder. The resident was prescribed Duloxetine for depression, and the care plan reflected the use of antidepressant medication. Despite these indicators, the PASARR Level II assessment, which is required when a Level I screening suggests a serious mental illness, was not completed as part of the pre-admission process. Interviews with facility staff, including social services and regional clinical operations, confirmed that while the PASARR Level I screening was completed, the Level II evaluation was not initiated or completed for this resident. Facility policy requires verification of a Level I PASARR screening prior to admission to identify serious mental illness or intellectual disability, but does not require a new Level I for readmissions. The lack of a timely PASARR Level II assessment could result in the resident not receiving necessary specialized mental health services, as noted by staff during interviews.

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