Failure to Notify State Authority and Implement PASARR Recommendations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to comply with requirements for the Pre-Admission Screening and Resident Review (PASARR) process for several residents with mental health diagnoses. For three residents, the facility did not notify the State-designated authority when new mental health diagnoses were identified. Specifically, one resident was diagnosed with major depressive disorder, recurrent, but this was not reported to the State authority as required. Another resident received a new diagnosis of schizoaffective disorder, bipolar type, which was also not communicated to the State. A third resident was diagnosed with schizoaffective disorder, but the facility did not update the State-designated authority with this information. Additionally, for a resident with a history of schizoaffective disorder, bipolar disorder, attempted self-harm, and violent behaviors, the facility did not incorporate PASARR recommendations into the care plan. The PASARR had recommended a crisis/safety plan due to the resident's history, but the care plan lacked this intervention. Interviews and record reviews confirmed that the required crisis/safety plan was not present in the clinical record, and staff were unaware of the PASARR recommendations for this resident. The facility's own PASARR policy requires notification of the State-designated authority when a resident receives a new mental health diagnosis or shows signs of mental illness not previously identified. Despite this, the responsible staff did not conduct audits to ensure compliance, and new diagnoses were not consistently reported or incorporated into care plans as required. These failures were identified through review of clinical records, facility documentation, and staff interviews.