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F0645
D

Inaccurate PASRR Level I Screening for Mental Illness

Huntington, Texas Survey Completed on 07-16-2025

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 the accuracy of the Pre-admission Screening and Resident Review (PASRR) Level I assessment for one resident. Upon admission, the resident had a documented diagnosis of bipolar disorder, which is a mental illness. However, the PASRR Level I screening completed after admission was marked as negative for mental illness, despite the presence of this diagnosis in the resident's medical records, physician orders, and care plan. The resident's records also indicated active management of mood problems related to bipolar disorder, including medication interventions. Interviews with facility staff confirmed that the MDS Coordinator, who was responsible for PASRR screenings, entered the incorrect information on the PASRR Level I assessment. The Director of Nursing and the Administrator both acknowledged that the MDS Coordinator was responsible for ensuring the accuracy of PASRR screenings and that the screening should have reflected the resident's mental health diagnosis. The facility did not have a policy related to PASRR at the time of the deficiency.

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