Failure to Notify State Mental Health Authority After New Mental Health Diagnosis
Penalty
Summary
The facility failed to notify the State mental health authority for a Pre-admission Screening and Resident Review (PASRR) after a resident was newly diagnosed with bipolar disorder. Record review showed that the resident's initial PASRR, completed in February 2022, did not require a Level II determination. However, after the resident received a new diagnosis of bipolar disorder in August 2024, there was no evidence in the clinical record that a referral for a new PASRR determination was made at that time. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the referral was not submitted until May 2025. The deficiency involved a resident who had a significant change in mental health status, specifically a new diagnosis of bipolar disorder, and the facility did not coordinate timely assessment or referral to the State mental health authority as required.