Failure to Complete Required PASARR Level II Evaluations Prior to Admission
Penalty
Summary
The facility failed to ensure that Level II Preadmission Screening and Resident Review (PASARR) evaluations were completed prior to admission for three out of five residents reviewed. According to facility policy, individuals identified with a mental disorder or intellectual disability must have a Level II PASARR evaluation completed before admission, and the facility should not admit such individuals unless the State mental health authority has determined the need for specialized services. However, record reviews showed that residents with diagnoses including major depressive disorder, adjustment disorder, dementia with behaviors, depression, stroke, panic disorder, bipolar disorder, and PTSD were admitted without completed Level II PASARR evaluations, despite documentation indicating that such evaluations were required. For one resident, the Level I PASARR form indicated mood and psychotic disorders and a need for Level II evaluation, but no documentation of completion was found. Another resident had two Level I PASARR forms, with one not completed or signed and no evidence of a Level II evaluation, despite relevant diagnoses. A third resident's Level I PASARR form also showed a need for Level II evaluation, but again, no documentation was present. Staff interviews confirmed that referrals for Level II evaluations had been sent but not returned due to a backlog with the evaluator, and that the facility was admitting residents without the required paperwork, contrary to policy.