Failure to Incorporate PASRR Level II Recommendations into Care Plans
Penalty
Summary
The facility failed to ensure that recommendations from Level II Preadmission Screening and Resident Review (PASRR) evaluations were incorporated into the care plans for two of five sampled residents. For one resident with multiple complex diagnoses, including anxiety, depression, and a mental health condition related to trauma, staff completed a Level I PASRR indicating the need for a Level II evaluation. Although a Notice of Determination was received confirming the need for specialized behavioral health services, the Level II evaluation was not found in the resident's records, and its recommendations were not integrated into the care plan. The Social Services Director confirmed that the evaluation and its recommendations were received via email but were not implemented as required by facility policy. Similarly, another resident with dementia and depression, who was receiving antipsychotic, antianxiety, and antidepressant medications, was identified as needing a Level II PASRR evaluation following a Level I screen. However, no Level II evaluation was found in this resident's records. The Social Services Director acknowledged that such evaluations should be obtained and included in the resident's records when a serious mental illness is identified. These omissions were in direct violation of the facility's policy and state regulations.