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F0645
D

Failure to Submit PASRR Reevaluation for Resident with Mental Health Disorders

Statesville, North Carolina Survey Completed on 07-03-2025

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 submit a request for an updated Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted with mental health disorders. The resident had a Level I PASRR determination with no expiration date and was admitted with diagnoses including bipolar disorder, anxiety disorder, and dementia without behavioral disturbance, as well as psychotic and mood disturbances. The resident's medical record showed active physician orders for antipsychotic and antidepressant medications, and the admission Minimum Data Set (MDS) assessment indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Despite ongoing use of psychotropic medications, there was no evidence that a PASRR reevaluation request had been submitted or completed since the initial Level I determination. Interviews with facility staff revealed that the social worker was responsible for submitting PASRR reevaluation requests but was not always informed when residents with mental health diagnoses were admitted. The administrator confirmed that a PASRR audit had been completed prior to the resident's admission, and the need for a reevaluation for this resident was overlooked because the admission occurred after the audit. As a result, the required PASRR reevaluation was not requested for the resident with significant mental health diagnoses and ongoing psychotropic medication use.

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