Failure to Complete Required PASRR Resident Review After 30-Day Exempted Stay
Penalty
Summary
The deficiency involves the facility’s failure to complete a required PASRR Resident Review Level 1 screening for a resident with a serious mental illness whose stay exceeded the 30‑day exempted hospital discharge period. The resident was initially admitted and later readmitted, with diagnoses including bipolar disorder, COPD, and hypertension. An MDS dated 1/6/2026 documented moderately impaired cognitive skills for daily decision-making and a need for moderate assistance with toileting, lower body dressing, and personal hygiene, as well as the use of antipsychotic medication. The resident’s H&P indicated the resident had capacity to understand and make decisions. Record review showed physician orders dated 11/18/2025 for quetiapine fumarate 100 mg by mouth at bedtime for bipolar disorder with aggressive angry outbursts, and a care plan dated 11/19/2025 addressing bipolar disorder with administration of antipsychotic medications as ordered. An initial psychiatric evaluation dated 11/21/2025 included a treatment plan to titrate medications according to symptoms, observe for deterioration in function, and provide emotional support for treatment compliance. A PASRR Level 1 screening dated 11/18/2025 indicated the resident tested positive for a serious mental illness. During interviews and concurrent record reviews, the MDS nurse confirmed that every resident has a PASRR Level 1 completed prior to admission and that a positive Level 1 typically triggers a more in‑depth Level 2 mental health evaluation. The PASRR Level 2 letter for this resident, dated 11/18/2025, documented that a Level 2 evaluation was not required due to an exempted hospital discharge, and specified that if the resident remained in the facility longer than 30 days, the facility must resubmit a new Level 1 screening as a Resident Review on the 31st day. The MDS nurse and DON both stated that the resident’s stay had exceeded 30 days and acknowledged that the facility was responsible for submitting a new Resident Review Level 1, which was not done. The facility’s admission policy and the DHCS PASRR Level 2 Screening Process webpage both indicated that for exempted hospital discharges, if the stay exceeds 30 days, the NF must submit a Resident Review Level 1 within the specified timeframe, which did not occur for this resident.
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