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F0645
D

Failure to Provide Accurate PASRR Screening for Mental Illness

Austin, Texas Survey Completed on 06-12-2025

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 provide an accurate Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident who had a documented diagnosis of Major Depressive Disorder. Upon admission, the resident's PASRR Level 1 screening, conducted by an acute care hospital, was marked negative for mental illness, intellectual disability, and developmental disability, despite the presence of a mental health diagnosis. The resident's medical record and care plan confirmed the diagnosis of Major Depressive Disorder and the use of antidepressant medication. Multiple staff interviews, including those with two MDS coordinators, the DON, and the administrator, confirmed that the resident's diagnosis should have resulted in a positive Level 1 PASRR screening, which would have triggered a Level 2 evaluation. The facility's PASRR policy requires that if a Level 1 screening is found to be incorrect, the MDS coordinator or designee must contact the hospital or responsible case worker to correct the form, or submit a new screening if necessary. In this case, the failure to identify and correct the inaccurate PASRR Level 1 screening resulted in the resident not being properly identified as having a mental illness, which could have affected the provision of specialized services. The deficiency was identified through record review and staff interviews, all of which acknowledged the oversight and its potential impact on the resident's care.

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