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F0646
D

Failure to Timely Update and Submit PASRR Documentation After Significant Change in Condition

Burley, Idaho Survey Completed on 08-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update and submit required Level I PASRR documentation for residents with mental illness (MI) or developmental disability (DD) following significant changes in their diagnoses or conditions, as mandated by Idaho Medicaid Plan Benefit 16.03.26.475.03. For three residents, the facility did not complete or timely submit updated Level I PASRRs when new diagnoses or changes in mental health status occurred. One resident was prescribed Lithium Carbonate for mood stabilization, which required an updated Level I PASRR to be submitted within two working days, but this was not done. Another resident's diagnosis was changed from depressive disorder to bipolar disorder, necessitating an updated Level I PASRR, which was not completed until nearly two months later. In both cases, facility staff acknowledged the delay or lack of awareness regarding the required timeframe for submission. A third resident had a longstanding diagnosis of schizophrenia that was not reflected in the PASRR documentation for over eight years. The original Level I and Level II PASRRs only documented depressive disorder and mental retardation, omitting the schizophrenia diagnosis. The omission was only recently identified and an updated Level I PASRR was sent to the state, with the facility still awaiting an updated Level II PASRR. These failures resulted in inaccurate assessments and a lack of timely notification to the appropriate authorities as required by regulation.

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