Failure to Refer for PASRR Level II Evaluation After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II PASRR Evaluation after the resident received a new diagnosis of bipolar disorder. Initially, the resident's PASRR Level I Screening did not indicate the presence of a mental illness, intellectual disability, or developmental disability, and therefore, a Level II Evaluation was not completed at that time. However, after the resident was later diagnosed with bipolar disorder, there was no evidence in the medical record that a subsequent PASRR Screening or Evaluation was conducted as required. The resident in question was an older female admitted with multiple diagnoses, including sick sinus syndrome, heart failure, and, later, bipolar disorder. The MDS Assessment confirmed the bipolar disorder diagnosis, but the facility did not initiate the necessary PASRR Level II Evaluation following this new diagnosis. The MDS Coordinator acknowledged that the evaluation should have been completed and was unable to provide a reason for the omission, as she was not employed at the facility during that period. Additionally, the facility did not have a policy related to PASRR Evaluations and relied on following state guidelines.