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F0645
D

Inaccurate PASRR Assessments for Mental Health Diagnoses

Lacey, Washington Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected the mental health diagnoses for two residents. For one resident admitted with depression and anxiety, the Level 1 PASRR did not document a serious mental illness indicator, nor was Section IV Service Needs and Assessor Data completed to indicate if a Level II evaluation was necessary. Similarly, another resident admitted with depression, bipolar disorder, and anxiety had a Level 1 PASRR that did not document these serious mental illness indicators, and Section IV was also left incomplete. According to facility policy, the Social Worker, Admissions Coordinator, or designee is responsible for reviewing completed screening forms prior to admission and ensuring they are placed in the electronic medical record. However, interviews and record reviews revealed that these steps were not properly followed, resulting in inaccurate PASRR documentation for both residents. Staff acknowledged the inaccuracies upon review.

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