Failure to Notify State Authority of New Psychiatric and Intellectual Disability Diagnoses
Penalty
Summary
The facility failed to notify the state designated authority when a resident received new diagnoses of psychotic disorder with delusions and mild intellectual disabilities. The resident, who was initially admitted with diagnoses including stroke, metabolic encephalopathy, diabetes, and cognitive decline, later received additional psychiatric and intellectual disability diagnoses as documented in various clinical notes and physician orders. Despite these significant changes in the resident's condition, the required notification to the state authority was not made. The social worker responsible for PASARR coordination believed that because the resident already had a Level 2 PASARR, there was no need to update the state authority when new diagnoses were made. However, upon contacting the state designated authority, it was clarified that the resident did not have a Level 2 PASARR and that any new psychiatric diagnosis should have been reported so the state could evaluate the need for specialized services. This misunderstanding led to a failure in updating the PASARR process as required by policy. Throughout the period in question, there was a lack of communication between the psychiatric group and the social worker, which contributed to the oversight. The facility's policy requires the social worker to track, make referrals, care plan, and update PASARR with any changes, but these steps were not followed when the resident's diagnoses changed. Interviews with facility staff confirmed the breakdown in communication and the failure to notify the state authority as required.