Failure to Complete Accurate PASRR Assessments and Submit Required Level II Evaluations
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were accurate and that a Level II PASRR was submitted for one resident with relevant mental health diagnoses. Record review showed that the resident was admitted with diagnoses including mood disorder, insomnia, dementia, and bipolar disorder. The Level I PASRR indicated no suspicion or diagnosis of Serious Mental Illness or Intellectual Disability, and a Level II PASRR evaluation was not completed, despite the resident's diagnoses. During an interview, the Assistant Director of Nursing (ADON) acknowledged that PASRR audits were being conducted but stated that outside of these audits, no further action had been taken for existing residents. The ADON also indicated a misunderstanding of which diagnoses require Level II submission, as she did not submit for bipolar disorder. Additionally, the facility did not have a PASRR policy in place.