Failure to Obtain Required PASRR Level 2 Evaluations for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations were obtained for five out of nine residents reviewed who had indications of serious mental illness (SMI). According to facility policy, a positive PASRR Level 1 screen for SMI requires a referral for a Level 2 evaluation, which should be conducted prior to admission or upon identification of new SMI diagnoses. For several residents, documentation showed either a referral for a Level 2 evaluation was made but not followed up on, or no referral was made at all despite the presence of SMI diagnoses such as depression, anxiety, psychotic disorder, and schizophrenia. In one case, a resident was referred for a Level 2 evaluation after a change in condition, but there was no evidence in the records that the evaluation was obtained or that follow-up occurred, even months after the referral. Interviews with facility staff confirmed that there was no established process for tracking or following up on PASRR Level 2 referrals to ensure completion. Staff acknowledged that residents with SMI should have been referred for Level 2 evaluations and that these evaluations are important for ensuring appropriate mental health care. Record reviews for the affected residents showed missing or incomplete PASRR Level 2 documentation, and in some cases, no updated PASRR Level 1 was completed after new mental health diagnoses were identified. These actions and omissions resulted in the facility not obtaining required PASRR Level 2 determinations for residents with SMI.