Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR evaluation after the resident was identified as positive during the Level I PASARR screening. The resident was admitted with diagnoses of Depression and Post Traumatic Stress Disorder (PTSD), both of which are considered serious mental health conditions. The Level I PASARR screening indicated a positive result, which should have triggered a referral for a Level II evaluation to determine the need for specialized mental health services or a higher level of care. During an interview and record review, the Minimum Data Set Coordinator (MDSC) confirmed responsibility for reviewing PASARR results and following up with Level II evaluations as needed. The MDSC acknowledged that the Level II evaluation was not completed for this resident, stating it was missed. The facility's policy requires coordination of recommendations from Level II PASARR determinations with resident assessment and care planning, but this process was not followed in this case.