Failure to Complete Accurate PASRR Screenings and Referrals for Mental Health Diagnoses
Penalty
Summary
The facility failed to refer residents with diagnosed mental disorders to the appropriate state-designated authority for evaluation and determination, as required by PASRR (Preadmission Screening and Resident Review) regulations. For three residents reviewed, the facility did not ensure that PASRR Level I screenings accurately reflected their mental health diagnoses, nor did they initiate PASRR Level II evaluations when indicated. Specifically, one resident with multiple sclerosis, Alzheimer’s disease, and depression was admitted without a PASRR Level II, and their Level I screening did not document the depressive disorder despite the use of an antidepressant. Another resident with quadriplegia, depression, and anxiety was admitted and readmitted without a PASRR Level II, and their Level I screening omitted documentation of depression and anxiety. Additionally, a third resident with major depressive disorder, anxiety disorder, and alcohol dependence had a Level I screening that only noted mild or situational depression, omitting the major depression and anxiety diagnoses. Staff interviews confirmed that the PASRR Level I screenings were incomplete or inaccurate and that Level II evaluations were not completed when required. The Social Services Director acknowledged that the screenings should have included all relevant diagnoses and that Level II evaluations were necessary but not performed. These findings were based on record reviews and staff interviews, demonstrating a pattern of failure to properly identify and refer residents with mental health needs for appropriate evaluation.