Failure to Resubmit PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit required Preadmission Screening and Resident Review (PASRR) Level I evaluations for two residents with mental health diagnoses. For one resident with a history of bipolar disorder and major depressive disorder, the initial PASRR Level I screening was negative and the resident was admitted as an Exempted Hospital Discharge. However, the facility did not resubmit a new Level I screening on the 31st day as required, and there was no current Level I screening in the resident's record. Interviews with staff revealed that no individual had been assigned responsibility for ensuring the timely resubmission of the PASRR, and the process was not clearly defined among staff members. For another resident with a diagnosis of schizophrenia, the initial PASRR Level I screening was positive for suspected mental illness, and a Level II evaluation was required. The state agency closed the case after determining that the resident was isolated for health or safety reasons, instructing the facility to submit a new Level I screening to reopen the case. The facility did not submit the required new Level I screening, and as a result, the Level II evaluation was never completed. Staff interviews confirmed that the process for submitting PASRR evaluations was unclear, and the individual previously responsible for submissions was no longer employed at the facility. Throughout the investigation, staff including the Admissions Assistant, MDS Coordinator, DON, and Administrator acknowledged the lack of clear assignment of responsibility and failure to act promptly on PASRR-related correspondence. The facility's policy required maintenance of PASRR documentation and timely action on positive screenings, but these procedures were not followed for the two residents reviewed.