Failure to Submit Level II PASRR Evaluations for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to submit requests for Level II Preadmission Screening and Resident Review (PASRR) evaluations for four residents who were admitted with serious mental health disorders. Each of these residents had a Level I PASRR determination and documented diagnoses such as bipolar disorder, post-traumatic stress disorder (PTSD), major depressive disorder, and anxiety. Despite these diagnoses and the use of psychotropic medications including antipsychotics, anticonvulsants, and antidepressants, there was no evidence in the medical records that a Level II PASRR evaluation was requested or completed for any of the residents reviewed. Staff interviews revealed that the admissions process involved verifying the presence of a PASRR determination, but the responsibility for requesting a Level II evaluation was not consistently executed. The Admission Coordinator stated that she ensured residents had a PASRR and would request one if missing, but had not submitted any Level II requests since starting her position. The Social Worker confirmed that she was not informed by the clinical team to submit Level II requests and acknowledged that such requests should have been made for residents admitted with mental health diagnoses. The Administrator also confirmed that the process required the Social Worker to submit Level II requests when indicated, but these were overlooked for the residents in question. Documentation in the residents' records, including care plans, physician and psychiatric notes, and medication administration records, consistently showed ongoing treatment for serious mental illnesses. However, the absence of Level II PASRR evaluations meant that the required federal and state screening process for individuals with serious mental illness or intellectual disability was not followed for these residents. This deficiency was identified through record review and staff interviews, with all involved parties acknowledging that the necessary requests for Level II PASRR evaluations were not made.