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F0644
D

Failure to Initiate PASRR Level II Referral After New Mental Health Diagnosis

Pittsboro, North Carolina Survey Completed on 07-08-2025

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 ensure that a Preadmission Screening and Resident Review (PASRR) Level II referral was made after a resident received new mental health diagnoses. Record review showed that the resident was originally admitted with a PASRR Level I completed, and a Level II PASRR was previously halted due to dementia being the primary diagnosis. However, the resident was later diagnosed with unspecified psychosis and started on an antipsychotic medication, but there was no documentation of a new Level II PASRR referral following this significant change in mental health status. Further review of the resident's comprehensive Minimum Data Set (MDS) confirmed that the resident was not coded for a Level II PASRR despite the new diagnosis. Interviews with facility staff revealed that the social worker was unaware of the need for a Level II PASRR referral after the new mental health diagnosis and cited difficulty keeping up with residents. The administrator acknowledged that the social worker was new to the role and required further education regarding PASRR requirements.

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