Failure to Notify State Authority and Request PASRR Level II After Significant Change in Condition
Penalty
Summary
The facility failed to notify the North Carolina Medicaid Uniform Screening Tool (NC MUST), the State Mental Health or Intellectual Disability Authority, when residents with mental disorders experienced a significant change in condition, and did not request a Preadmission Screening and Resident Review (PASRR) Level II re-evaluation for two residents. For one resident with a history of schizoaffective disorder, bipolar type, and post-traumatic stress disorder, the medical record showed a decline in mental status and worsening anxiety symptoms, as well as changes in psychiatric medications. Despite these changes and the addition of new diagnoses after the initial PASRR Level I screening, the social services staff were unaware of the updates and did not initiate a Level II PASRR screening as required. Another resident, originally admitted with moderate dementia and anxiety, had their diagnoses updated to include bipolar disorder and was prescribed antipsychotic medication for mood disorder. The facility did not refer this resident for a Level II PASRR evaluation after the diagnosis change. Interviews with the Director of Social Services confirmed a lack of awareness regarding the updated diagnoses and the need for PASRR re-evaluation following significant changes in mental health status and treatment.