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F0645
D

Failure to Complete and Notify PASARR Screening for Mental Health Disorder

Temple, Texas Survey Completed on 06-05-2025

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 resident with mental health disorders received an accurate PASARR Level 1 screening and that the local authority was notified as required. Record review showed that the resident, a female with diagnoses including post-traumatic stress disorder and bi-polar disorder in full remission, had a PASARR Level 1 screening indicating the presence of a mental illness, intellectual disability, or developmental disability. Despite this, there was no evidence that the facility notified the local authority or obtained a PASARR Level II evaluation as required by policy. Interviews with facility staff confirmed that the MDS Coordinator is responsible for completing and modifying the MDS and PASARR screenings, and that failure to submit the PASARR in a timely manner could result in the resident not receiving necessary services. The facility's policy requires follow-up on all residents with positive PASARR Level I screenings, including obtaining a Level II evaluation or documenting attempts to do so, but this process was not followed for the resident in question.

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