Failure to Complete Required Level II PASARR for Exempted Hospital Discharge Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete a required Level II Preadmission Screening and Resident Review (PASARR) for a resident admitted under an exempted hospital discharge who remained in the facility for more than 30 days. The admission MDS dated 09/24/2025 documented that Resident 3 was admitted on a specified date, and the Level I PASRR form dated 09/22/2025 identified indicators of Serious Mental Illness, known or suspected mood disorders, and functional limitations related to a known or suspected behavioral health disorder. The same Level I PASRR documented that the resident was admitted as an Exempted Hospital Discharge, with the attending physician certifying the individual was likely to require fewer than 30 days of NF services, and it stated that no Level II evaluation was indicated at that time due to the exempted hospital discharge, but that a Level II must be completed if the scheduled discharge did not occur. The discharge MDS showed that the resident was discharged on 11/28/2025, confirming that the resident remained in the facility from 09/22/2025 to 11/28/2025, which exceeded 30 days. Review of the electronic health record showed no evidence that a Level II PASARR evaluation was completed during this stay. In an interview, the Social Services Director stated that when a resident is admitted with an exempted hospital discharge Level I PASRR, the resident must discharge within 30 days or a Level II PASARR must be completed and sent to the PASARR office within 30 days if the resident does not discharge, and acknowledged that Resident 3 did not have a Level II PASARR completed within 30 days. The Social Services Director also stated they did not know the resident had been admitted with an exempted hospital discharge Level I PASARR, and the Administrator confirmed that the Level II PASARR should have been completed within 30 days for this resident.
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