Deficient PASRR Screening and Documentation for Mental Illness and Intellectual Disability
Penalty
Summary
The facility failed to complete a required Level II Pre-admission Screening and Resident Review (PASRR) for one resident and did not ensure the accuracy of a Level I PASRR for another. One resident was admitted with diagnoses including unspecified bipolar disorder, insomnia, and depression, and their PASRR indicated diagnoses of bipolar disorder, depressive disorder, and PTSD. Despite these diagnoses and the resident exhibiting symptoms of depression following the loss of a spouse, the PASRR did not identify any disorder resulting in functional limitations or issues with interpersonal functioning, and it was determined that a Level II PASRR was not required. The resident's care plan, however, included trauma-informed care for PTSD and the use of psychotropic medications for bipolar disorder and insomnia. The Director of Clinical Reimbursement confirmed that a Level II PASRR should have been completed for residents with such diagnoses who remain in the facility for more than 30 days. For another resident, the facility did not update the Level I PASRR to reflect new diagnoses of anxiety and insomnia that were added after the initial admission. The PASRR only listed depressive disorder, omitting the later diagnoses. The Director of Clinical Reimbursement stated that updating PASRRs is typically the responsibility of Social Services, but there was uncertainty about the regular review process for PASRRs and whether all relevant diagnoses were being consistently documented. The facility's policy requires preadmission screening and review of PASRRs for suspicion of serious mental illness or intellectual disability, but these procedures were not followed as required in these cases.