Failure to Complete PASRR Level II for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II was completed for residents who received new mental health diagnoses, as required. For three residents, medical record reviews showed that although PASRR Level I screenings were completed prior to admission, subsequent new diagnoses of mental health conditions such as anxiety disorder, mood affective disorder, schizophrenia, post-traumatic stress disorder (PTSD), bipolar disorder, and major depressive disorder were documented in the electronic medical records. Despite these new diagnoses, no PASRR Level II reviews were completed for these residents, contrary to the recommendations noted in their initial PASRR Level I screenings, which specified that a Level II should be resubmitted if a new mental health diagnosis was suspected or if there was a significant change in condition. Staff interviews revealed a lack of awareness and understanding regarding the requirement to complete PASRR Level II reviews upon admission, readmission, or when a new mental health diagnosis was made. The social worker responsible for PASRR paperwork indicated she typically only completed Level II reviews for residents with limited Level II status or when there were changes in behaviors, and was not always informed of new mental health diagnoses. The administrator confirmed her understanding that PASRR Level II should be completed in a timely manner under these circumstances, but this was not consistently implemented for the residents in question.