Failure to Complete Required PASRR Evaluations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to complete new Preadmission Screening and Resident Review (PASRR) evaluations as required for two residents. For one resident, the Minimum Data Set (MDS) assessments documented diagnoses of anxiety, depression, and bipolar disorder, with a PASRR short-term approval that had an end date. The electronic health record lacked documentation of a new PASRR being completed, and there was no evidence in the progress notes of efforts to move the resident toward discharge to a lower level of care before the short-term approval expired. Additionally, psychiatric progress notes included a diagnosis of PTSD that was not reflected in the PASRR documentation. The administrator confirmed that social services were responsible for PASRR assessments and acknowledged the deficiency was identified during a mock survey, but a new PASRR had not yet been completed. For the second resident, the MDS assessment included multiple mental health diagnoses and documented the use of antipsychotic and antidepressant medications. The care plan identified behavioral problems and risks related to medication side effects. The medical diagnosis sheet listed several mental health conditions, but the PASRR Level 1 screen only included an unspecified mood disorder and indicated no PASRR disability was present. The rationale for not updating the PASRR was based on the absence of a status change, despite the presence of multiple mental health diagnoses and behavioral symptoms.