Failure to Complete Required PASARR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to initiate new Level I PASARR screenings for four residents with known mental illnesses, as required for Pre-admission Screening and Resident Review (PASARR). Documentation for these residents showed diagnoses such as schizoaffective disorder, bipolar disorder, schizophrenia, major depressive disorder, and delusional disorders. However, their PASARR records were either incomplete, did not indicate a reasonable basis for suspecting mental illness or developmental delay, or incorrectly stated that no Level II PASARR was required despite the presence of qualifying diagnoses. There was no documentation to show that appropriate Level II PASARR screenings had been completed for these residents. Interviews with facility staff revealed confusion and inconsistent understanding of PASARR requirements, particularly regarding which residents required new screenings and the process for updating expired screenings. The Social Services Director and Admissions Director each described different responsibilities and procedures for ensuring PASARR compliance, with both referencing a belief that residents admitted prior to a certain date were "grandfathered" and did not require new screenings. Facility policy required compliance with federal and state PASARR standards and obtaining complete PASARR documentation from referral sources, but the observed practice did not align with these requirements.