Failure to Complete PASARR Level II Referrals for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) Level I forms were completed accurately and that appropriate Level II PASARR referrals were made for two residents. Specifically, one resident was admitted with diagnoses of depression, anxiety disorder, and insomnia, and another with depression and insomnia. Both residents had their Level I PASARR forms completed, which documented their mental health diagnoses, but there was no evidence in their electronic health records that referrals for Level II evaluations were made as required by facility policy and regulatory standards. During a review of the medical records, the facility administrator confirmed that referrals for Level II evaluations should have been made for both residents. The facility's policy states that Level II PASARR evaluations are required for residents identified with indicators of serious mental illness or intellectual disabilities during Level I screening or at any time during their stay. The lack of documentation and failure to initiate Level II referrals constituted the deficiency identified by surveyors.