Failure to Refer Resident for Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for further evaluation as required by the Pre-admission Screening and Resident Review (PASARR) program when the resident was diagnosed with major mental illness and related conditions. Record review showed that the resident had multiple diagnoses, including post-traumatic stress disorder (PTSD), depression, anxiety, and bipolar disorder, with several PASARR Level I and II screenings conducted over time. Despite documentation of these mental health diagnoses and prescribed medications, several PASARR II forms indicated that no further evaluation for specialized services was needed, and concerns related to mental health were not always documented. Additionally, inconsistencies were found in the documentation of PTSD on the Minimum Data Set (MDS) assessments. Staff interviews revealed that errors in the PASARR process were not identified or corrected in a timely manner. The Social Services Manager acknowledged missing errors on previous PASARR forms, and facility leadership confirmed that staff should have identified and addressed these errors. As a result, the resident was not consistently referred for appropriate evaluation by the state-designated authority, as required for individuals with major mental illness or related conditions.