Failure to Complete Required PASRR Level II Evaluation Prior to Admission
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) process was properly completed for a resident with a diagnosis of major depressive disorder and vascular dementia. Record review showed that a PASRR Level I screening indicated the presence of a serious mental illness (SMI) and required a Level II evaluation prior to admission. However, there was no evidence in the resident's record that a PASRR Level II evaluation was completed before the resident was admitted. Additionally, the resident's record lacked behavioral health provider notes and the required Level II evaluation summary, despite documentation of severely impaired cognition after admission. Interviews with facility staff revealed that the standard admission process was not followed for this resident, who was transferred from a sister facility. The Admissions Director and Administrator In Training both stated they did not review the resident's PASRR documentation prior to admission and were unaware that a Level II evaluation was required. The PASRR Level I was also filled out incorrectly, and the necessary referral for a Level II evaluation was not made before the resident's admission.