Failure to Refer Resident for Required Level II PASRR Evaluation
Penalty
Summary
The facility failed to follow up and refer a resident with multiple mental health diagnoses, including schizoaffective disorder, bipolar disorder, insomnia, and depression, for a required Level II PASRR (Pre-admission Screening and Resident Review) evaluation. The resident's admission records and clinical physician orders documented these diagnoses and included prescriptions for medications such as Ziprasidone Hydrochloride, Trazadone, and Amitriptyline Hydrochloride. The initial PASRR Level I screen indicated the need for a Level II onsite assessment, but there was no evidence that this assessment was completed. Throughout the survey, multiple facility staff, including the Administrator, DON, Social Service Coordinator, Nurse Consultant, and Social Service Director, were unable to provide documentation of a completed Level II PASRR for the resident. The Social Service Director confirmed that the staff responsible for admissions had not consistently followed up on PASRR requirements, and that the current admissions staff was new and still learning the process. The facility's own policy requires compliance with PASRR procedures and timely follow-up, but the necessary referral to the state-designated authority for the Level II assessment was not made until the time of the survey.