Failure to Update PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were properly updated for two residents with mental health diagnoses. For one resident admitted with unspecified dementia, mood disorder, major depressive disorder, and insomnia, the Level I PASRR indicated no suspicion of serious mental illness or intellectual disability, and a Level II PASRR was not completed, despite the presence of secondary mental health diagnoses. Similarly, another resident admitted with unspecified dementia, mood disorder, major depressive disorder, and generalized anxiety disorder had a Level I PASRR that did not trigger a Level II evaluation, even though the resident had a primary diagnosis of dementia and additional mental health conditions. Interviews and record reviews revealed that the Social Services Director was responsible for reviewing diagnoses and completing PASRR screenings but was not familiar with the specific regulatory requirements. The process relied on information from psychiatry and GDR meetings to identify new diagnoses, but there was a lack of understanding regarding when a Level II PASRR was required. The facility's policy stated that all applicants should be screened according to state Medicaid rules, with the Social Services Director responsible for tracking PASRR status, but this was not consistently followed, leading to the deficiency.