Failure to Complete Required PASARR Level 2 Referrals for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for two residents with mental health diagnoses. For one resident admitted with major depressive disorder, insomnia, and post-traumatic stress disorder (PTSD), the PASARR documented depression but omitted PTSD and insomnia, and there was no evidence that a required Level 2 referral was sent for further evaluation. For another resident admitted with major depressive disorder, bipolar disorder, anxiety disorder, and borderline personality disorder, the PASARR indicated the presence of serious mental illness (SMI) and noted that a Level 2 referral was required, but no evidence of such a referral was found in the medical record. The facility's policy required that if a Level 1 PASARR indicated possible SMI, intellectual disability (ID), or related disorder (RD), a Level 2 referral should be made to the state PASARR representative for further assessment. The Social Service Director acknowledged responsibility for reviewing PASARRs on admission and sending Level 2 referrals when indicated, but admitted that the required process was not followed for these two residents. This lapse was identified during a review of records and staff interview.