Failure to Refer Resident for Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with newly identified mental health diagnoses was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required. Record review showed that the resident was admitted with a diagnosis of Bipolar Disorder and subsequently acquired additional diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder. Despite these new diagnoses, there was no documentation of a Level II PASRR evaluation in the clinical record. Interviews with facility staff confirmed that a Resident Review form should have been submitted to the state agency for evaluation and determination for Level II services, but this was not done after the resident acquired the new mental health diagnoses.