Failure to Refer for PASRR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation after the identification of new mental health diagnoses. The resident was originally admitted with a diagnosis of Multiple Sclerosis and, at the time of admission, had no documented mental illness or disorder, resulting in a negative PASRR screening. However, subsequent diagnoses were made, including Adjustment Disorder, Depression, Anxiety Disorder, and Delusional Disorder, with the first new diagnosis appearing in May 2023 and the most recent in December 2024. Despite these new mental health diagnoses, there was no documented evidence in the resident's medical record that a PASRR Level II Evaluation was conducted or that a referral was made to the PASRR office as required. During an interview, the facility's social worker confirmed that a new PASRR should be completed and submitted whenever a new mental health diagnosis is identified, but the facility was unable to provide evidence that this process occurred for the resident in question.