Failure to Complete PASARR Level 1 Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that an initial Preadmission Screening and Resident Review (PASARR) Level 1 was completed prior to the admission of a resident with multiple mental health diagnoses, including bipolar disorder, depression, anxiety disorder, and unspecified dementia. Upon review of the resident's clinical record, no PASARR Level 1 documentation could be located, and the only submission provided was from 2008, which was deemed inappropriate due to potential changes in the resident's diagnoses. The resident's care plan indicated the use of psychotropic medications for behavior management, mood swings, depression, and anxiety, further highlighting the need for proper screening. Interviews with facility staff revealed a lack of awareness and understanding regarding the necessity and purpose of the PASARR Level 1 screening. The Regional Director of Clinical Services and the Business Office Manager both confirmed that a current PASARR Level 1 was required for admission, and that the absence of this documentation meant the facility could not determine the appropriateness of the resident's placement. The facility's policy also required a PASARR Level 1 to be completed and retained in the resident's medical record prior to admission, which was not followed in this case.