F0644

E

Failure to Request Level II PASRR Evaluations After New Serious Mental Health Diagnoses

Salisbury, North Carolina Survey Completed on 01-02-2026

Penalty

Fine: $20,385

Summary

The deficiency involves the facility’s failure to request Level II Preadmission Screening and Resident Review (PASRR) evaluations after new serious mental disorder diagnoses or significant changes in condition were identified for multiple residents who previously had Level I PASRR status. For one resident, a Level I PASRR completed prior to admission instructed that paperwork be resubmitted for a Level II evaluation if a new mental health diagnosis was suspected or if there was a significant change in condition. After admission, this resident was diagnosed with dementia with behavioral disturbance, schizophrenia, and anxiety, and was treated with olanzapine for schizophrenia, with ongoing psychiatric follow-up and consideration of gradual dose reduction. Despite these new diagnoses and ongoing psychiatric management, there was no documented evidence that a Level II PASRR evaluation was requested, and the resident’s name remained on an internal list of residents needing PASRR referrals without indication of completion.

Another resident had a Level I PASRR completed prior to admission with the same instruction to resubmit for Level II if a new mental health diagnosis or significant change occurred. This resident was admitted with schizophrenia and later received additional diagnoses of severe depression, dementia, and bipolar disorder. Psychiatric notes documented that the resident was stable on the current regimen and would be seen routinely for schizophrenia, depression, and bipolar disorder. However, the medical record contained no documentation that a Level II PASRR evaluation was requested. The resident’s name also appeared on the handwritten list of residents needing PASRR Level II evaluations and was not crossed off, and facility staff could not provide a date when the submission would be completed.

A third resident had a Level I PASRR completed prior to admission with instructions to resubmit for Level II if a new mental health diagnosis or significant change occurred. This resident was later diagnosed with psychosis, dementia, bipolar disorder, anxiety, and schizophrenia, and psychiatric documentation showed ongoing follow-up every four weeks for schizophrenia, bipolar disorder, and anxiety, including assessment for gradual dose reduction of psychiatric medications. Despite these multiple serious mental health diagnoses, there was no documented evidence of a Level II PASRR determination request, and the resident’s name remained uncrossed on the list of residents needing PASRR referrals. A fourth resident was admitted with a Level I PASRR status documented on an FL-2 form and a history of stroke; after admission, additional diagnoses of dementia with psychotic disorder, bipolar disorder, and unspecified psychosis were added. A significant change MDS assessment noted that bipolar disorder was diagnosed after admission and that a significant change in status assessment had been completed, yet the MDS still reflected a Level I PASRR status. The Director of Social Services confirmed this resident was on the list of those needing PASRR referral and that no referral had been initiated. Interviews with the MDS nurse, Social Work Director, and DON confirmed that residents with new mental health diagnoses or significant changes had been identified, but the process to submit Level II PASRR requests had not been carried out for these residents.

Facility staff interviews further clarified the actions and inactions that led to the deficiency. The MDS nurse stated she understood that when a resident had a change in condition along with a new mental health diagnosis, she was to notify the Social Work Director for a Level II PASRR referral, and she had created and shared a handwritten list of 25 residents with new mental health diagnoses requiring referral. The Social Work Director reported that she was responsible for initiating Level I or Level II PASRR requests when notified by the MDS nurse of a significant change or new mental health diagnosis and acknowledged that the residents in question were on an audit list of names that still needed to be submitted for Level II evaluations. The list of 25 residents showed that the names of the affected residents were not crossed off, indicating that submissions had not been completed, and the Social Work Director was unable to provide dates when these submissions would occur. The DON, who had recently assumed the role, stated her understanding that Level II PASRR requests should be completed in a timely manner upon admission or readmission of residents with mental health diagnoses and whenever there was a change in condition or new mental health diagnosis, but she was not aware of the specific residents on the list and confirmed that the issue of missed PASRR screenings remained a concern.