Failure to Complete Accurate PASRR Assessments and Timely Level II Referrals
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) assessments were accurate, revised, or submitted for Level II evaluation as required for several residents with indicators of Serious Mental Illness (SMI) or related conditions. In multiple cases, residents were admitted with documented diagnoses such as depression, anxiety, and mood disorders, and were receiving psychotropic medications, yet their Level I PASRR screenings either did not identify these SMI indicators or, when identified, did not result in the required Level II referral. For example, one resident with a mood disorder and on antidepressant medication was not referred for a Level II PASRR despite the SMI indicator being present on the Level I screening. Staff interviews confirmed that these referrals should have been made but were not completed as required. Additionally, the facility did not submit new or revised PASRR Level I screenings for residents who were admitted under a 30-day hospital exemption but remained in the facility beyond the exemption period. In these cases, residents with SMI indicators, such as mood or anxiety disorders and use of psychotropic medications, were not referred for Level II PASRR evaluations after their stays extended past 30 days. Staff acknowledged that the process required a new Level I PASRR and referral for Level II evaluation in such situations, but this was not done for the affected residents. Record reviews and staff interviews consistently showed that the facility's PASRR process failed to accurately identify residents with SMI indicators and did not ensure timely referrals for Level II evaluations as required by regulation. This resulted in residents with mental health needs not being properly assessed for appropriate placement and services during their stay.