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F0645
D

Failure to Timely Complete and Submit PASARR Documentation for Residents with Mental Illness or Intellectual Disabilities

Detroit, Michigan Survey Completed on 07-02-2025

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 Preadmission Screening and Annual Resident Review (PASARR) forms (DCH-3877 and DCH-3878) were reviewed, revised, and submitted to the state agency in a timely manner for two residents with mental illness or intellectual/developmental disabilities. For one resident with undifferentiated schizophrenia and severe cognitive impairment, the PASARR-ARR was completed, but the required Level II Determination was not documented, and the physician had not completed the necessary form due to lack of notification. The social work and nursing departments did not notify the physician in a timely manner, resulting in a delay in the process. For another resident with dementia, psychotic and mood disturbances, and severe cognitive impairment, the annual PASARR forms were missing from the medical record. The social worker indicated that the corporate social worker was handling the forms due to their part-time status, but could not provide evidence that the annual form was awaiting physician signature. The facility's policy requires annual completion and maintenance of these forms in the electronic medical record, but this was not followed for the two residents reviewed.

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