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F0645
D

Failure to Complete Required PASARR Screenings and Referrals for Residents with Mental Disorders

Chicago, Illinois Survey Completed on 08-07-2025

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 refer two residents for appropriate PASARR (Preadmission Screening and Annual Resident Review) evaluations and did not perform additional screening for one resident diagnosed with a new mental disorder. For one resident, the initial OBRA screening did not indicate any mental illness or developmental delay at admission, but subsequent medical records showed a diagnosis of schizophrenia and the use of antipsychotic medication. Despite this new diagnosis, the facility did not have a PASARR Level 2 evaluation in the resident's chart, and staff interviews confirmed that a referral for further assessment should have been made but was not completed. Another resident's admission record included multiple diagnoses, such as dementia and delusional disorders, but the only available documentation was an older interagency certification that did not specify the resident's physical or mental condition or required level of services. Staff confirmed that this document was not equivalent to a PASARR Level 1 screening and that no such screening had been completed for this resident. The facility's admissions and social services staff acknowledged that every resident should have a PASARR Level 1 screening and that the process for electronic submission had only recently been implemented, leaving some residents without proper screening. Facility policy required preadmission screening and resident review prior to admission and updates as needed, with responsibility assigned to the admissions director and administrator. However, interviews and documentation revealed that these procedures were not consistently followed, resulting in the lack of required PASARR screenings and referrals for residents with mental health diagnoses or changes in condition.

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