Failure to Complete Required PASARR Level 2 Evaluation for Resident with Mental Illness
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with diagnoses of Bipolar Disorder and Major Depressive Disorder received the required Level 2 OBRA (Omnibus Budget Reconciliation Act) evaluation following a positive Level 1 PASARR (Preadmission Screening and Resident Review) screening. The resident's electronic medical record showed an admission date and documented recent treatment for mental illness, including the use of psychotropic medications. Despite these findings, there was no evidence in the medical record that a Level 2 evaluation was completed or that the Level 1 screening was referred to the Community Mental Health Services Program (CMHSP) as required. Interviews with facility staff revealed that the MDS Nurse, responsible for PASARR completion, did not send the Level 1 assessment to the CMHSP because the necessary documentation was not transferred from the resident's previous facility. As a result, the nurse did not receive notification to follow up with the local CMHSP. Additionally, the Social Services Coordinator confirmed that the resident was not receiving mental health services and that the resident's representative had not been approached regarding the option to accept or decline such services. The facility's policy required notification to the state's PASARR program for a Level 2 screen when indicated, but this process was not followed in this case.