F0644

D

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

Greensboro, North Carolina Survey Completed on 12-19-2025

Penalty

No penalty information released

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 PASRR history detail dated 5/16/11 showed only a Level I PASRR had been completed, which at that time indicated no mental health diagnosis and did not meet Level II criteria. The resident was later admitted with a diagnosis that included major depressive disorder, and the active diagnosis list showed bipolar disorder, unspecified, added on 4/18/19 and schizophrenia, unspecified, added on 7/20/24. Review of the resident’s electronic and paper medical record revealed no evidence that a request for a Level II PASRR determination was ever submitted, and the MDS annual assessment indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability/related condition.

In interviews, the social worker responsible for PASRR evaluations at the time of the new serious mental health diagnoses stated she typically only reviewed PASRRs for new admissions or when a Level I PASRR had an expiration date. She acknowledged that the resident’s new diagnoses of bipolar disorder and schizophrenia represented a significant change in mental health but confirmed it was not her normal practice to submit a request for a Level II PASRR evaluation. The Administrator reported that the facility received the resident’s Level I PASRR from the hospital and was unsure who was responsible for resubmitting PASRR information when new mental health diagnoses were identified. The Administrator further stated that it was not the facility’s normal practice to resubmit PASRR information after admission and that this was not something the facility was doing.