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F0644
D

Failure to Refer Residents for PASRR Evaluation After New Mental Illness Diagnoses

Cooper, Texas Survey Completed on 06-18-2025

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 residents with new diagnoses of mental illness were properly referred for Preadmission Screening and Resident Review (PASRR) evaluations. In the case of one male resident with a new diagnosis of psychotic disorder with delusions, the initial PASRR Level 1 screening and MDS assessment did not indicate a mental illness. However, after admission, the resident was prescribed psychiatric medication and received a new diagnosis of psychotic disorder. Despite this change, neither a Form 1012 nor a new PASRR Level 1 screening was submitted to notify the local authority, as confirmed by the PASRR Manager, MDS Coordinator, and Administrator during interviews. The care plan for this resident also did not address PASRR needs. Similarly, a female resident with a new diagnosis of post-traumatic stress disorder (PTSD) was not referred for a PASRR review. Her initial PASRR Level 1 screening indicated no evidence of mental illness, and her care plan addressed trauma history but not PASRR requirements. The MDS Coordinator believed that PTSD was not a qualifying mental illness for PASRR and therefore did not complete the necessary forms. However, the PASRR Program Manager clarified that PTSD is a qualifying diagnosis and that a Form 1012 should have been completed. The Regional Reimbursement Nurse also acknowledged that the omission could have resulted from the diagnosis not being explicitly listed on the PASRR forms. These deficiencies were identified through record reviews and staff interviews, which revealed that the facility did not have a policy regarding PASRRs and that staff responsible for PASRR referrals were not consistently submitting required documentation when residents received new qualifying mental health diagnoses. This failure affected at least two residents reviewed for PASRR, as neither was referred for further evaluation or services following the identification of a new mental illness diagnosis.

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