Failure to Incorporate PASRR Level II Recommendations into Care Plans
Penalty
Summary
The facility failed to incorporate recommendations from the Pre-admission Screening and Resident Review (PASRR) Level II Determinations into the care plans for two residents. For one resident with diagnoses including seizure disorder, depression, bipolar disorder, and schizophrenia, the PASRR compliance report indicated noncompliance with disability-specific specialized services, rehabilitative services, and community placement supports. The care plan for this resident lacked multiple required components as identified by the clinical reviewer, despite the resident being observed as well-groomed and not displaying behaviors requiring staff intervention during the survey period. Another resident, diagnosed with diabetes mellitus, anxiety disorder, depression, and post-traumatic stress disorder, was observed to be tearful and upset over recent events, including changes to her care plan and being sent to the emergency department for evaluation. The PASRR compliance report for this resident also found the facility noncompliant with providing disability-specific specialized services, rehabilitative services, and community placement supports, with multiple required care plan components missing. These findings were based on observation, record review, and interviews with residents and staff.