Failure to Request Level II PASRR After New Serious Mental Illness Diagnoses
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who developed serious mental health diagnoses after admission. The resident was admitted with medical diagnoses including hypertension, hyperkalemia, and hyperlipidemia, and a Level I PASRR completed on 11/01/2021 indicated no mental health diagnosis and did not meet Level II criteria. Later, the active diagnosis list showed generalized anxiety disorder and depressive disorder as active beginning 03/26/2025, and a psychiatrist’s note dated 01/20/2026 documented a presenting problem of mood disorder with psychosis/bipolar, with Zyprexa 5 mg PO at bedtime prescribed for this condition. The MDS assessment reflected a diagnosis of bipolar disorder but indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability/related condition. Record review and staff interviews revealed that no request for a Level II PASRR evaluation was found in the resident’s electronic or paper medical record despite these new mental health diagnoses. The MDS Coordinator stated that her usual practice was to notify the Business Office Manager (BOM) when residents received new mental illness diagnoses so the BOM could submit a Level II PASRR request to the state agency, but she acknowledged she failed to notify the BOM when the resident’s new mental health diagnoses were added in March 2025. The BOM confirmed she was responsible for requesting Level II PASRR evaluations and reported she had not been informed of the resident’s anxiety disorder, depressive disorder, or later bipolar disorder diagnosis. The Administrator stated that the Level I PASRR received after admission showed no mental illness and that the Level II PASRR evaluation should have been completed when the new mental illness diagnoses were added in March 2025.
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