Failure to Accurately Document PASRR Level II Status in MDS Assessments
Penalty
Summary
The facility failed to accurately document the PASRR Level II status for three residents in their Minimum Data Set (MDS) assessments, despite each resident having a valid PASRR Level II determination on file. For each of the three residents, the PASRR identified serious mental illness and/or intellectual or developmental disabilities, along with specific diagnoses such as Major Depressive Disorder, Generalized Anxiety Disorder, Alcohol Dependence, Schizoaffective Disorder, Mood Disorder, and Intermittent Explosive Disorder. The PASRRs also outlined the need for specialized services, including ongoing psychiatric medication management and individual therapy by licensed behavioral health professionals. However, the corresponding MDS assessments failed to reflect the residents' PASRR Level II status as required by the 2024 RAI Manual. Staff interviews revealed that the MDS Coordinator relied on the electronic health record (EHR) and, if necessary, consulted the facility Social Worker to determine PASRR status. It was noted that after a facility name change and EHR transition, some medical records did not transfer correctly, which may have contributed to the omission. Despite the PASRR documents being uploaded into the EHR prior to the MDS completion dates, the required information was not accurately coded in the MDS, contrary to facility policy and RAI Manual instructions.