Failure to Complete Required PASARR Screening on Admission for Resident With Serious Mental Disorder
Penalty
Summary
The deficiency involves the facility’s failure to complete a required PASARR Level I screening on admission for a resident with documented serious mental disorders. The resident’s face sheet shows an admission and latest return in early January 2019 and lists diagnoses including delusional disorders, psychotic disorders, anxiety disorder, and major depressive disorder. The resident’s care plan, last revised in early May 2025, identifies ongoing delusions related to diagnoses of delusional disorder, unspecified dementia with behavioral disturbance, and other psychotic disorder not due to substance or psychological condition. During the survey on July 29, 2025, the surveyor was unable to locate any PASARR documentation in the resident’s EMR and requested it from the Administrator and DON. On July 29, 2025 at 12:25 p.m., the Social Services Director stated that the former Social Services Director had been responsible for PASARR submissions and acknowledged that the resident should have had a PASARR Level I completed, and that the resident’s psychiatric diagnoses would have triggered a PASARR Level II. The Social Services Director also stated that all residents should at least have a PASARR Level I completed. On July 30, 2025, the surveyor received a Notice of PASRR Level I Screen Outcome for the resident dated July 29, 2025, indicating a determination of “Refer to Level II Onsite,” demonstrating that the PASARR Level I was only completed during the survey and not at the time of admission. This failure occurred despite a facility policy, revised in November 2017, that requires a Level I screen for all potential admissions and coordination of care based on PASARR determinations, including referrals for Level II review for residents with newly evident or possible serious mental disorder, intellectual disability, or related condition.
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