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F0645
D

Failure to Complete Required PASARR Level II Evaluation

Hagerstown, Maryland Survey Completed on 05-14-2025

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 that a required Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for a resident with documented mental health and developmental conditions. Record review showed that the resident's PASARR Level I screening did not indicate a trigger for Level II evaluation or a 30-day short-term admission exemption, and there was no evidence of further screening or exemption coordination prior to admission. Despite the resident being care planned for agitation, schizoaffective disorder, and developmental delay, the necessary Level II evaluation was not conducted as required. During staff interview, the facility's social worker confirmed that both preadmission and post-admission PASARR Level I forms lacked documentation of a Level II review or exemption. The post-admission PASARR specifically noted that a Level II was required for intellectual disability, but no Level II clearance was obtained. The deficiency was acknowledged by facility staff and administration during the survey, with no additional evidence provided to demonstrate compliance.

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