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F0644
D

Failure to Incorporate PASARR Recommendations into Resident Care Plan

Danbury, Connecticut Survey Completed on 05-07-2025

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

A deficiency occurred when the facility failed to incorporate the recommendations from a Level 2 Preadmission Screening and Resident Review (PASARR) determination into the assessment and care plan for a resident with a history of depression, anxiety, bipolar disorder, and opioid dependence. The resident was admitted with these diagnoses and was prescribed Buprenorphine-Naloxone for opioid dependence. The PASARR Level 2 outcome specifically recommended that the resident be provided with services and support, including access to a support group for recovery from substance abuse and mental health counseling. Despite these recommendations, the facility did not update the resident's care plan to reflect the need for a support group or mental health counseling. The social worker responsible for PASARR compliance did not review the Level 2 PASARR recommendations and was unaware of the requirement to provide support group services. As a result, the resident was not offered or referred to a support group for recovery from substance abuse, nor was this intervention included in the care plan. Interviews with facility staff confirmed that the social worker did not submit the PASARR within the required timeframe and did not follow up on the recommendations after receiving the Level 2 approval. The facility's policy requires that PASARR recommendations be incorporated into the resident's assessment and care planning, but this was not done in this case, resulting in a failure to coordinate assessments and services as required.

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