Failure to Complete Required PASARR Screenings for Residents with Mental Illness or ID/DD
Penalty
Summary
The facility failed to ensure that required Pre-admission Screening and Annual Resident Review (PASARR) Level I screenings were completed for two residents with diagnoses of mental illness or intellectual/developmental disabilities. For one resident with dementia and a history of suicidal ideations, there was no current 3877 form or exemption certification (DCH-3878) found in the electronic health record, and the annual PASARR was not completed as required. This resident was noted to have intact cognition based on a recent MDS assessment. For another resident with schizoaffective disorder, bipolar type, and altered mental status, the current 3877 form was also missing, and the exemption certification had expired. This resident had severely impaired cognition according to the most recent MDS assessment. Facility staff, including the social worker and the nursing home administrator, confirmed during interviews that the required PASARR documentation was not completed or updated as needed. The facility did not have a specific PASARR policy, stating that they follow OBRA regulations.