Failure to Submit PASRR Level II for Resident with Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a PASRR Level II evaluation for a resident who was admitted with diagnoses including schizophrenia, bipolar disorder, and major depressive disorder. According to the facility's policy, all residents with mental disorder (MD) or intellectual disability (ID) diagnoses are to be screened prior to admission and referred for a Level II evaluation if indicated, including upon a significant change in status. Review of the electronic medical record and paper medical records revealed no evidence that a PASRR Level II was completed or submitted for this resident, despite qualifying diagnoses. Staff interviews confirmed that the Social Services department holds weekly behavior meetings to discuss new admissions, diagnoses, and resident behaviors. During these meetings, the resident's qualifying diagnoses were discussed, but the necessary PASRR Level II documentation was not submitted. The Minimum Data Set (MDS) indicated the resident was not considered by the state PASRR process to have a serious mental illness or related condition, despite active diagnoses of schizophrenia and no psychological services being documented.