Failure to Refer Resident for PASARR Level II After New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that a resident who received a new diagnosis of bipolar disorder was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. The resident was initially admitted with a Level I PASARR approved for a temporary period and later received another Level I PASARR screening indicating Level II services were not required. However, after a psychiatric assessment documented a new diagnosis of bipolar disorder, there was no evidence in the electronic medical record that a Level II PASARR screening was completed or that a referral was made to the appropriate state agency. The facility's social worker confirmed in an interview that no new referral for a Level II PASARR screening was made following the new diagnosis.