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F0645
D

Failure to Complete Timely PASRR Level 2 Screening Delays Resident Transfer

Windham, Connecticut Survey Completed on 08-18-2025

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 complete a PASRR Level 2 screening for a resident whose initial PASRR Level 1 approval was valid for only seven days. The resident, who had diagnoses including congestive heart failure, COPD, depression, PTSD, and bipolar disorder, was admitted with a PASRR Level 1 that did not require a Level 2 referral at the time. However, upon expiration of the initial PASRR Level 1, the facility did not initiate the required Level 2 screening, despite the resident's psychiatric diagnoses. This oversight was not identified until after the resident received a Notice of Medicare Non-Coverage and the family sought transfer to a VA-connected facility. The delay in completing the PASRR Level 2 screening resulted in the resident being unable to transfer to the desired facility until the process was finalized. As a result, the resident was required to remain at the current facility as a private pay resident for an additional fifteen days. Interviews with the Director of Social Services and the Administrator confirmed that the facility did not follow the required process for timely PASRR Level 2 screening, which directly impacted the resident's transfer and financial responsibility.

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