Failure to Incorporate PASARR Level II Recommendations into Care Plan
Penalty
Summary
The facility failed to coordinate the Preadmission Screen and Resident Review (PASARR) Level II process for a resident who required mental health services. Specifically, the social services department did not ensure that the recommendations from the resident's Level II PASARR evaluation were included in the resident's care plan, as required by facility policy. The Level II PASARR evaluation, which identified diagnoses such as conversion disorder, schizophrenia, and anxiety, contained specific interventions for the resident's care that were not reflected in the care plan. Record review showed that the resident's care plan did not include the recommended interventions from the Level II PASARR, despite the social services director's statement that such recommendations should be incorporated word for word. The administrator also confirmed the expectation that these recommendations be included in assessments and care plans. This omission was identified through interviews and joint record reviews, which confirmed that the care plan was general and not personalized with the required PASARR recommendations.