Failure to Accurately Complete and Update PASARR Assessments and Referrals
Penalty
Summary
The facility failed to ensure accurate completion and timely updating of Level I Pre-admission Screening and Resident Review (PASARR) assessments for multiple residents with diagnoses or indicators of serious mental illness (SMI), intellectual disabilities (ID), or related conditions (RC). For several residents, including those with documented diagnoses of psychotic and anxiety disorders, the Level I PASARR forms were either not updated to reflect current diagnoses or did not result in appropriate referrals for Level II evaluations, despite SMI indicators being present. In some cases, the original Level I PASARR was completed years prior and had not been revised to account for new or updated mental health diagnoses. Record reviews and interviews with facility staff revealed that residents with marked SMI indicators on their Level I PASARR forms did not have corresponding Level II referrals, as required by facility policy and regulatory standards. Staff interviews confirmed awareness that these residents should have had updated Level I PASARR assessments and referrals for Level II evaluations, but these actions were not completed. For example, one resident with a diagnosis of depression and marked anxiety and psychotic disorders on their PASARR did not have an updated assessment or referral, and another resident's PASARR failed to indicate their known anxiety disorder. The facility's policy states that any indicators of SMI, ID, or RC on the Level I PASARR should prompt a referral for a Level II assessment. However, the review found that for at least five residents, the PASARR process was not followed as required, resulting in incomplete or inaccurate documentation and a lack of necessary referrals. These deficiencies were confirmed through joint record reviews and staff interviews, which consistently indicated that the expected procedures for PASARR completion and referral were not adhered to.