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F0644
D

Failure to Provide Required Specialized Behavioral Health Services After PASARR Level II Evaluation

Fremont, Ohio Survey Completed on 06-03-2025

Penalty

Fine: $26,685
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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 provide required specialized behavioral health services to a resident with significant mental health diagnoses, as mandated by the state-designated mental health authority following a PASARR level II evaluation. The resident, who had diagnoses including anxiety, depression, bipolar disorder, and psychophysiologic insomnia, was admitted after being approved for nursing facility placement with the stipulation that specialized services, such as a comprehensive psychiatric assessment and mental health counseling, be provided. However, review of the medical record showed that a comprehensive psychiatric assessment was not completed until several months after admission, and only in response to a resident-to-resident altercation and ongoing aggression, rather than as part of the required specialized services. Additionally, there was no evidence that the resident was ever seen, assessed for, or referred to mental health counseling, as required by the PASARR level II determination. Staff interviews confirmed the absence of documentation for mental health counseling and indicated a lack of awareness regarding the completion of the required psychiatric assessment. The facility's policy outlined the process for PASARR screenings and the provision of specialized services, but these requirements were not met for the resident in question.

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