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F0644
D

Failure to Complete PASRR Referrals After New Mental Health Diagnoses

Georgetown, Delaware Survey Completed on 07-31-2025

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 new referrals for Pre-Admission Screening and Resident Review (PASRR) were completed when residents received new mental health diagnoses and started new psychotropic medications. For one resident, a PASRR Level I screening was initially completed documenting dementia and anxiety, but later, a new diagnosis of psychotic disorder with delusions was added, and an antipsychotic medication was prescribed. Despite these significant changes, a referral for a new PASRR review was not completed at the time of the new diagnosis and medication initiation, as confirmed by staff interviews and record review. For another resident, a transfer from another facility included diagnoses of dementia with psychotic disturbance and anxiety disorder, and a new diagnosis of delusional disorder was added after admission. The medical record showed a previous PASRR Level II screen that excluded the resident based on a primary neurocognitive disorder, but there was no evidence that a new PASRR referral was submitted after the new diagnosis of delusional disorder. Staff interviews confirmed a lack of awareness and action regarding the need for PASRR resubmission following the updated diagnosis.

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