Failure to Refer for PASRR Level II After New Mental Health Diagnosis
Penalty
Summary
The facility failed to make a required referral to the Oklahoma Health Care Authority (OHCA) for a Pre-Admission Screening and Resident Review (PASRR) Level II after a resident was newly diagnosed with a serious mental health disorder. Initially, the resident's PASRR Level I form indicated no mental health disorder, and no Level II referral was deemed necessary. However, a diagnosis of bipolar disorder was later added to the resident's medical record. Despite this significant change in the resident's status, as documented in a subsequent assessment showing intact cognition, there was no evidence that a PASRR Level II referral was made. The MDS coordinator confirmed the absence of documentation for such a referral following the new diagnosis.