Failure to Obtain and Document Final PASARR Determinations
Penalty
Summary
The facility failed to ensure that a Level I Pre-admission Screening (PAS) and, when indicated, a Level II Pre-admission Screening and Resident Review (PASARR) were completed for two residents with mental health diagnoses. Both residents had intact cognition and were diagnosed with schizoaffective disorder, one with auditory hallucinations and the other with an acute exacerbation. Documentation in their medical records showed that while a PAS notice was present, there was no evidence that a final PASARR determination had been received from the lead agency for either resident. The director of nursing confirmed during an interview that the final PASARR determinations could not be found in the medical records for these residents. The facility's policy required that copies of PASARR approvals be uploaded into each resident's medical record, but this was not done. The process for obtaining final determinations had recently changed from fax to electronic requests, and the facility had not been following the new procedure, resulting in the missing documentation.