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F0644
D

Failure to Refer Resident for Level II PASRR After New Mental Health Diagnosis

Louisburg, North Carolina Survey Completed on 05-08-2025

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 refer a resident with a newly identified serious mental illness for a Level II Preadmission Screening and Resident Review (PASRR). The resident was originally admitted with diagnoses of major depressive disorder and recurrent anxiety disorder, and a Level I PASRR was completed at that time, indicating that no further screening was required unless a significant change in mental health status occurred. On a later date, the resident received a new diagnosis of bipolar disorder with depression, which constitutes a significant change and requires a Level II PASRR referral. Record review showed there was no documentation that a Level II PASRR referral was completed after the new diagnosis. The resident's annual Minimum Data Set (MDS) assessment confirmed the absence of a Level II PASRR. During interviews, the Social Worker acknowledged responsibility for submitting PASRR referrals and stated that new mental health diagnoses were reviewed daily in interdisciplinary meetings, but this resident had been overlooked. The Administrator confirmed that the Social Worker was responsible for the PASRR review process.

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