Failure to Submit PASRR Level II Evaluation for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted with multiple serious mental health diagnoses. Documentation showed that the resident had a history of bipolar disorder, post-traumatic stress disorder (PTSD), depression, and anxiety, and was receiving several psychiatric medications, including antidepressants, antianxiety medications, and an antipsychotic. Despite these diagnoses and ongoing psychiatric symptoms, such as hallucinations, there was no evidence in the medical record that a Level II PASRR evaluation had been requested or completed. The resident's care plan addressed mood alterations, PTSD, and the risk of drug-related side effects, and included interventions such as psychiatric consultations and monitoring for medication effects. However, the care plan did not reference the need for a PASRR Level II evaluation. Medical and psychiatric notes documented ongoing symptoms, medication adjustments, and the addition of antipsychotic and antianxiety medications, but there was no indication that these changes prompted a reassessment of the resident's PASRR status. Interviews with facility staff revealed that the social worker relied on the hospital's PASRR Level I screening, which did not identify a serious mental illness, and assumed that all relevant diagnoses had been entered into the screening tool. The social worker acknowledged not submitting a Level II PASRR request after admission, despite the resident's diagnoses, medication changes, and reports of hallucinations. The administrator deferred to the social worker regarding PASRR requirements, and the clinical coordinator confirmed that no Level II evaluation had been submitted, as the Level I determination did not indicate a serious mental illness and there was no significant change in the resident's condition.