Failure to Submit Level II PASRR Evaluations for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit requests for Level II Preadmission Screening and Resident Review (PASRR) evaluations for residents who developed new mental health diagnoses or experienced significant changes in condition. Record reviews for six residents revealed that although PASRR Level I screenings were completed prior to admission, each included recommendations to resubmit paperwork for Level II PASRR if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Despite this, there was no evidence in the medical records that requests for Level II PASRR evaluations were submitted after residents were diagnosed with conditions such as anxiety disorder, bipolar disorder, major depressive disorder, psychotic disorder, or schizoaffective disorder. Interviews with facility staff indicated a lack of follow-through on PASRR requirements. The Social Worker, who began employment in August 2025, acknowledged responsibility for completing PASRR paperwork and was aware that Level II PASRR should be completed for residents with new mental health diagnoses or significant changes. However, she admitted she had not reviewed residents admitted prior to her start date or those readmitted, and could not provide a reason why the sampled residents did not have Level II PASRR evaluations completed. She confirmed that, based on their diagnoses, Level II PASRR evaluations should have been performed. The Administrator, who started in October 2025, was not aware of who was previously responsible for PASRR Level II requests and was unaware that the sampled residents lacked the required evaluations. He stated his understanding that Level II PASRR should be completed in a timely manner upon admission, readmission, or when a resident receives a new mental health diagnosis or experiences a significant change in condition. The absence of Level II PASRR evaluations for these residents was confirmed through both record review and staff interviews.