Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
A resident with a history of schizoaffective disorder, insomnia, depression, and generalized anxiety disorder was admitted to the facility without the completion of the required PASARR Level I screening prior to admission. Record review showed that the resident's care plan addressed depression related to schizoaffective disorder, and a psychiatric evaluation documented ongoing mental health concerns, including increased depression and anxiety. However, there was no evidence in the resident's electronic health record of a completed PASARR Level I Am screening report, as required by facility policy and federal regulations. Interviews with facility staff, including the MDS Coordinator, DON, and ADM, revealed a lack of clarity regarding the PASARR submission process and timelines. The MDS Coordinator acknowledged the requirement to submit the PASARR after the IDT meeting within 14 days, while the DON and ADM were uncertain about the specific timeframe for submission. The facility's PASRR policy mandates that the Level I screening be completed before admission, but this was not done for the resident in question, resulting in a deficiency related to the PASARR screening process.