Failure to Resubmit PASRR Level II for Residents Exceeding 30-Day Exemption
Penalty
Summary
The facility failed to resubmit the PASRR Level II evaluations for residents who were initially admitted under a 30-day hospital exemption but whose stays exceeded 30 days. This deficiency was identified through record review and staff interviews, and it was found to be true for three residents. For each of these residents, the original PASRR Level II documentation indicated that if the resident remained in the facility beyond 30 days, the facility was required to submit updated information, including the most current MDS, physician orders, social notes, and psychiatric information, to the state-designated authority (BLTC). However, this resubmission did not occur as required. The residents involved had significant medical and mental health diagnoses, including depression, anxiety, major depressive disorder, autonomic nervous system disorder, Parkinson's disease, and borderline personality disorder. Staff interviews confirmed that the required documentation was not submitted for these residents when their stays exceeded 30 days. Facility leadership acknowledged that the oversight should have been identified and addressed earlier, but the necessary updates were not made in a timely manner.