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F0645
D

Failure to Complete PASARR Level II Screening for Resident with Serious Mental Illness

Pomona, California Survey Completed on 07-25-2025

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 complete a required PASARR Level II screening for a resident with serious mental illness (SMI). The resident was admitted with diagnoses including depression, schizoaffective disorder, and schizophrenia. A PASARR Level I screening indicated a positive result for SMI, and the Minimum Data Set (MDS) assessment showed the resident had intact cognitive skills for daily decision making. Following the Level I screening, the California Department of Health Care Services (DHCS) sent a notification letter to the facility indicating that a Level II mental health evaluation was required to determine the need for specialized services. However, the facility did not respond to the DHCS notification letter or to two or more separate attempts by DHCS to communicate within 48 hours of the Level I screening. As a result of the facility's lack of response, the required PASARR Level II screening for SMI was not scheduled in a timely manner. Interviews with facility staff confirmed that the notification letter was received but not acted upon, and that the facility's policy required daily checks of the PASARR portal and follow-up on Level II determinations. The failure to respond and complete the Level II screening meant the resident did not receive a timely evaluation for specialized services related to their mental health condition.

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