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F0645
D

Deficient PASRR Screening and Evaluation for Residents with Mental Illness or Disability

Liberty, Texas Survey Completed on 06-04-2025

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 individuals identified with mental illness (MI), developmental disability (DD), or intellectual disability (ID) were properly evaluated for services, as required by the PASRR process, for two of five residents reviewed. For one resident, the PASRR Level 1 screening incorrectly listed dementia as the primary diagnosis without verification from a physician or supporting documentation, despite the resident having diagnoses of major depressive disorder and bipolar disorder and being prescribed antipsychotic and antidepressant medications. The MDS nurse admitted to not confirming the primary diagnosis with the physician and acknowledged the PASRR Level 1 was not accurate and needed to be redone. For another resident, the PASRR Level 1 form was incorrectly marked to indicate a short-term stay of less than 30 days, even though the resident was intended for long-term placement and had diagnoses including schizoaffective disorder and major depressive disorder, and was receiving antipsychotic medications. The MDS nurse responsible for the form was unsure why the error occurred and recognized that the mistake could have delayed services. The facility's policy requires accurate coordination with the PASRR program to ensure appropriate care and services for individuals with MI, DD, or ID, but this was not followed in these cases.

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