Failure to Complete Significant Change Assessment and PASRR Submission After New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a significant change assessment and submit a required Level II Preadmission Screening and Resident Review (PASRR) for one resident after the individual was diagnosed with major mental illness, specifically bipolar disorder and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. The resident's initial pre-admission screening did not indicate a major mental illness, and a previous Level II PASRR had only been submitted for an intellectual developmental disability. However, after the new mental health diagnoses were made, the facility did not submit a new Level II PASRR or conduct a significant change assessment as required by policy. Interviews with facility staff, including a charge RN and a social services staff member, confirmed that the significant change assessment was not completed following the new diagnoses. The staff acknowledged that this assessment should have been performed to ensure the resident received appropriate services and that staff were informed of the resident's updated needs. Record review also indicated that the resident was severely cognitively impaired at the time of the deficiency.