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F0644
E

Failure to Coordinate PASRR Services and Referrals After Mental Health Changes

Dover Foxcroft, Maine Survey Completed on 06-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure compliance with Pre-admission Screening and Resident Review (PASRR) requirements for two residents. For one resident, the PASRR Level II evaluation recommended specialized services including individual therapy, neuropsychiatric evaluation, rehabilitative therapies, and supportive counseling. However, the clinical record did not show evidence that these services were offered, provided, refused, or addressed in the resident's assessments or care planning. Interviews with facility staff confirmed the absence of appointments, referrals, or documentation related to these specialized services. For another resident, the clinical record indicated a history of suicidal talk and behaviors, a new diagnosis of schizophrenia, and recent incidents of suicidal ideation. Despite these changes, there was no evidence that the facility referred the resident for a new PASRR Level II determination as required after a significant change in mental health status or diagnosis. The PASRR assessment was not updated to reflect the resident's current condition, and required services such as psychiatric evaluation and individual therapy were not documented as provided or addressed in the care plan.

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