Failure to Complete Required PASRR Level I and Level II Evaluations for Residents With Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure required Preadmission Screening and Resident Review (PASRR) Level I and Level II evaluations were completed for residents with mental disorders or intellectual disabilities. One resident with moderate cognitive impairment and diagnoses including depression and schizophrenia had no evidence in the medical record that any PASRR screening was completed prior to or following admission in July 2025, which was confirmed by the DON. For a second resident with a diagnosis of schizoaffective disorder, the PASRR Level I dated 9/18/25 documented responses of “no” to questions regarding major mental illness, history of mental illness requiring more than outpatient treatment in the past two years, and current evidence of mental illness, and the Level I summary concluded there was no evidence of mental illness or intellectual disability, despite the documented schizoaffective disorder diagnosis. A third resident had a PASRR Level I dated 11/6/25 showing diagnoses including PTSD and schizophrenia, and the Level I summary indicated there was evidence of mental illness and that a PASRR Level II was required. For both the second and third residents, the medical records contained no evidence that the required PASRR Level II assessments were completed, even though one resident had signed a PASRR Level II informed consent form dated 10/14/25. In an interview, the DON confirmed that PASRR Level II assessments should have been completed for these two residents and stated that the staff member responsible for completing the assessments had been locked out of the PASRR system. The facility’s PASARR policy stated that the community would not admit new veterans with mental disorder or intellectual disability unless the appropriate state authority had made the required determinations prior to admission, but the documented screenings and missing Level II assessments did not align with these requirements.
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