Failure to Complete and Implement PASRR Level II Evaluations and Recommendations
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) processes were completed correctly for several residents, including the completion of Level II evaluations when indicated and the incorporation of Level II recommendations into care plans. For four out of six sampled residents, there were deficiencies in either referring for a PASRR Level II evaluation, obtaining the evaluation summary, or implementing the recommended behavioral health interventions. The facility's policy required that PASRR findings be reviewed and used to develop individualized care plans, but this was not consistently done. One resident with major depressive disorder and suicidal ideation was admitted without the PASRR Level II Initial Psychiatric Evaluation Summary in their record, and there was no evidence of behavioral health provider notes or assessments. The resident expressed willingness to receive behavioral health services but had not been seen by a provider. Staff interviews confirmed that referrals had been made but not followed up, and the administrator acknowledged that without the Level II summary, necessary interventions could not be incorporated into the care plan. Other residents with documented mental health diagnoses or behaviors indicating serious mental illness did not have timely PASRR Level II referrals or had care plans that failed to include the recommendations from completed Level II evaluations. For example, one resident with a history of suicide attempts and recent self-harm did not have the PASRR Level II recommendations integrated into their care plan, and behavioral health services were delayed. Staff acknowledged being behind on PASRR referrals and that multiple residents were awaiting evaluation. The administrator confirmed expectations for staff to review PASRRs for accuracy, refer for Level II evaluations when indicated, and implement recommendations into care plans, but these steps were not consistently followed.