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F0644
D

Failure to Coordinate PASRR Assessment for Resident with Serious Mental Disorder

Carthage, Texas Survey Completed on 08-13-2025

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 coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for a resident who was admitted with a diagnosis of schizoaffective disorder, bipolar type. Upon admission, the resident's PASRR Level 1 screening form indicated no evidence or indicator of a mental illness, and no PASRR Level II screening was completed. The admission Minimum Data Set (MDS) assessment also reflected that the resident was not considered by the state Level II PASRR process to have a serious mental illness, despite documentation of an active diagnosis of schizoaffective disorder and the resident being on psychotropic medication. The comprehensive care plan noted a mood problem related to this diagnosis. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for obtaining and reviewing PASRR documentation, acknowledged that the resident's PASRR Level 1 screening should have been positive for mental illness due to the diagnosis. The MDS Coordinator was not working full time at the facility during the resident's admission period. The Administrator confirmed that the correct PASRR documentation was expected to be on file and that inaccuracies in the screening should have been corrected to allow for a Level II evaluation. Facility policy required all new admissions to be screened for mental disorders per the Medicaid PASRR process, but this was not followed in this case.

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