Failure to Complete Accurate PASRR Assessment and Referral After Significant Change
Penalty
Summary
The facility failed to submit an accurate Level I PASRR (Pre-admission Screening and Resident Review) assessment for one resident and did not refer the resident for a Level II PASRR evaluation after a significant change in condition. The resident exhibited symptoms such as being withdrawn, having a flat affect, and requiring more assistance with activities of daily living. Despite these changes and a documented history of schizoaffective disorder, bipolar disorder, PTSD, anxiety disorder, homicidal ideations, auditory hallucinations, and mild intellectual disabilities, the Level I PASRR assessment did not include these mental health diagnoses, behaviors, symptoms, or related medications. The resident was also prescribed multiple psychotropic medications, including antipsychotics and medications for anxiety and behavior disturbances. The office manager, who was not a clinical professional, signed and submitted the PASRR assessment without conducting or reviewing the clinical information, as required by policy. There was a lack of consistent staff in the Admissions and Social Services departments, leading to administrative staff handling clinical documentation. The facility's own policy requires compliance with federal and state PASRR standards, but the process was not followed, resulting in the resident not being properly assessed or referred for necessary services after a significant change in their condition.