F0645

D

Failure to Accurately Complete PASRR Screening for Resident With Schizophrenia and Depression

Ocilla, Georgia Survey Completed on 01-18-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a complete and accurate PASRR Level I screening was submitted prior to or on admission for a resident with documented mental health diagnoses. Facility policy required that all residents be screened prior to admission using the PASRR process, that the facility obtain a copy of the PASRR and approval number, and that a Level II evaluation be performed if the screening was positive for serious mental illness or intellectual/developmental disability. The resident’s electronic health record showed admission with diagnoses including unspecified mild dementia with anxiety, schizophrenia (unspecified), and unspecified depression. The admission MDS documented active diagnoses of non-Alzheimer’s dementia, Parkinson’s disease, and schizophrenia, and indicated the resident received antidepressant medications. Physician orders showed ongoing treatment with escitalopram and mirtazapine for depression and risperidone for schizophrenia.

Despite these documented conditions, the resident’s PASRR Level I assessment indicated “No” for diagnoses of schizophrenia, anxiety, or depressive disorder, and the resident was not listed on the facility’s roster of residents with Level II PASRR determinations. During interview, the Administrator confirmed that the Social Services Director was primarily responsible for submitting Level I PASRR screenings and acknowledged that the resident did not have a Level II PASRR, despite having qualifying diagnoses. The Administrator further confirmed that the Level I PASRR screening had not been resubmitted with the qualifying diagnoses and explained that prior PASRR audits only reviewed the top three diagnoses on the DMA-6 form, which did not include the qualifying mental health diagnoses.