Failure to Complete Required PASRR Level II Evaluations After Positive Screenings
Penalty
Summary
The facility failed to ensure that two of four sampled residents were accurately screened for mental disorders or intellectual disabilities as required by the PASRR process. For one resident, the PASRR Level I Screening indicated that a Level II Mental Health Evaluation was required due to a suspected serious mental illness, but there was no documented evidence in the medical record of a follow-up call, inquiry to the Department of Health Care Services (DHCS), or submission of a new Level I PASRR screening. The MDS Assistant confirmed that while the Level I PASRR screening was completed, there was no documentation of any follow-up to address the need for a Level II evaluation. For another resident, the PASRR Level I Screening also resulted in a positive finding for serious mental illness, requiring a Level II Mental Health Evaluation. However, the medical record did not show that a new Level I Screening was submitted after the initial positive result. The MDS Nurse verified that a follow-up was required if the facility had not heard from the State agency within 72 hours, and acknowledged that a new Level I PASRR Screening should have been completed but was not. The Director of Nursing was informed and acknowledged these findings.