Failure to Accurately Complete PASARR Screening and Referral
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) Level I form was completed accurately and that a Level II PASARR referral was made for a resident with a diagnosis of anxiety disorder. Specifically, the resident was admitted with a diagnosis that included anxiety disorder, but this diagnosis was not marked in Section IA (Serious Mental Illness) of the Level I PASARR form. As a result, Section IV of the form indicated that no Level II evaluation was needed, contrary to the resident's documented medical condition. During a joint record review and interview, it was confirmed that the resident's diagnosis of anxiety disorder was present in their medical records but was omitted from the PASARR Level I form. Staff involved acknowledged that the diagnosis should have been included and that a Level II referral should have been made. The facility's administrator also stated that the PASARR form should accurately reflect all SMI diagnoses, but was unsure about the specific criteria for Level II referrals.