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F0641
D

Failure to Complete and Accurately Code PASRR Assessment

Hayward, California Survey Completed on 06-20-2025

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 Preadmission Screening and Resident Review (PASRR) assessment was completed and accurately coded for a resident with diagnoses of major depressive disorder and an eating disorder. The resident's admission record indicated a positive PASRR I, but a PASRR II was not completed due to the resident being placed in isolation as a health or safety precaution. Despite this, the Minimum Data Set (MDS) Coordinator was unaware that the PASRR II had not been completed and had not seen the relevant letter from the Department of Health Care Services (DHCS) indicating the assessment was not done. The MDS documentation was inconsistent, with one section indicating the resident was considered by the state PASRR II process to have a serious mental illness, while another section indicated the opposite. Interviews with facility staff, including the MDS Coordinator and the Medical Director, revealed a lack of awareness and monitoring regarding the completion and coding of the PASRR II assessment. The Medical Director confirmed the importance of the PASRR II screening for ensuring appropriate care and stated he was not informed that the assessment had not been completed. The facility did not have a process in place to track or report the status of PASRR II assessments to the physician, resulting in the resident not being properly assessed for care and services appropriate to their needs.

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