F0645

D

Failure to Ensure Accurate PASARR Screening and Timely Referral for Mental Health Services

Fort Worth, Texas Survey Completed on 12-11-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate PASARR Level 1 (PL1) screening and appropriate referral for a resident with a documented mental disorder. The resident was an adult male admitted with a diagnosis of bipolar disorder, was cognitively intact with a BIMS score of 15, and required substantial assistance with ADLs. His care plan documented an ADL self-care deficit, use of an antipsychotic medication for bipolar disorder, and depression. However, his PASRR Level 1 screening indicated there was no evidence of mental illness and no primary diagnosis of dementia, and the electronic health record contained no evidence that a PASRR Level 2 evaluation had been completed by the local mental health authority.

Interviews revealed conflicting and inaccurate information regarding whether and when the resident had been referred to the local mental health authority. One MDS coordinator stated the resident had been referred in September and evaluated in December, while another MDS coordinator stated the resident had not been referred and that she only initiated the referral in December after discovering the omission. She acknowledged that not having the resident assessed could result in him not receiving services he might qualify for and noted there had been confusion about the resident’s insurance coverage that might have contributed to the lack of referral. The facility’s policy required obtaining a PL1 from the referring entity prior to admission and submitting it via the portal within PASRR regulatory timeframes, but the inaccurate PL1 and failure to coordinate a timely PASRR Level 2 evaluation for this resident with bipolar disorder and depression led to the cited deficiency.