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F0644
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Failure to Complete Level 2 PASRR for Residents with New Mental Illness Diagnoses

Shelbyville, Illinois Survey Completed on 05-02-2025

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 obtain Level 2 Pre-admission Screening and Resident Review (PASRR) assessments for four residents who were diagnosed with severe mental illness after admission. In each case, the residents were initially admitted with no indication of mental illness or developmental disability, as documented by their original Level 1 PASRR screenings. However, subsequent diagnoses of severe mental illnesses such as Psychotic Disorder with Delusions, Bipolar Disorder, Psychosis, and Schizoaffective Disorder were made after admission. Despite these new diagnoses, there was no documentation of Level 2 PASRR assessments being completed for these residents in their comprehensive medical records. Interviews with facility staff revealed a misunderstanding of PASRR requirements, with staff believing that Level 2 PASRRs were only necessary for new admissions or in cases of significant change, rather than when a new mental illness diagnosis was made after admission. The facility's own policy required a Level 2 PASRR for residents with new mental illness diagnoses, but this was not followed. As a result, the facility did not coordinate appropriate assessments or referrals for services as required for residents with newly identified severe mental illnesses.

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