Failure to Implement PASARR-Recommended Customized Wheelchair Service
Summary
The deficiency involves the facility’s failure to incorporate PASARR Level II recommendations into a resident’s assessment, care planning, and transitions of care, specifically the provision of a customized manual wheelchair (CMWC) as a specialized service. The resident was an adult male with cerebral palsy, dementia, and speech disturbances, with a BIMS score of 03 indicating severe cognitive impairment and dependence on staff for ADLs. His care plan included requirements to complete and submit a new PL1 for any readmission or change of condition, notify the local authority and therapy department of PASARR-positive status, and hold an IDT meeting within 14 days of admission. A PASRR care plan meeting and PASRR Comprehensive Service Plan Form dated 08/06/25 documented that the IDT, including PASRR representatives, agreed the resident would receive habilitation coordination, independent living skills training, and a customized manual wheelchair as a new specialized service. Despite this agreement, the facility did not successfully submit the necessary NFSS request for the CMWC through the Simple LTC portal within the PASARR time frame. Portal records dated 08/15/25 and 11/07/25 showed the forms for the customized wheelchair were marked "form not accepted," and no NFSS was submitted. During observation, the resident was seen in a non-customized wheelchair, leaning to the left with his left hand dangling out of the chair, and attempts to interview him using a language line interpreter were unsuccessful due to unclear speech. The PTA reported that she recommended the CMWC at the PASRR meeting, the PASRR coordinator agreed, the wheelchair company assessed and measured the resident, and the physician signed the paperwork, but she was informed the NFSS was not accepted due to a discrepancy with the resident’s date of birth. Interviews with the MDS coordinator, DON, and business office manager revealed that the NFSS submission was rejected because of conflicting Social Security and date-of-birth information, and that the issue had been referred to the business office and corporate without resolution. The business office manager stated that the Social Security office had an older, incorrect date of birth that had become official and that she contacted an HHSC eligibility services clerk, who confirmed the birth date change in early August 2025. The PASRR staff reported that the facility did not reach out to PASARR support for assistance and explained that the facility should have inactivated the rejected PO1 and submitted a new one with the correct date of birth. The MDS coordinator stated that the head office changed the date on the declined PO1 but refused to cancel and resubmit it due to billing concerns, and she declined to contact PASARR support directly. The facility was unable to provide a PASRR policy when requested at entrance and exit interviews.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, depression, anxiety, and later bipolar disorder did not have a Level II PASRR request submitted to NC MUST when the serious mental illness diagnosis was added. The record showed antidepressant and anxiolytic orders, an MDS noting bipolar disorder and no Level II PASRR evaluation, and staff stated the DPD missed the diagnosis and delayed submitting the FL-2 and PASRR request until much later.
PASRR assessments were not updated for two residents after new mental health diagnoses were documented. One resident had records showing brief psychotic disorder, major depressive disorder, and later delusional disorder, with psychotropic orders for quetiapine and trazodone, while the PASRR did not reflect mental illness. Another resident had documented depression and anxiety, later behavioral health notes identifying major depressive disorder and decline-related concerns, and an escitalopram order for depression, but the PASRR also did not reflect mental illness.
Failure to Refer Residents With Mental Illness for PASRR Screening: The facility did not properly coordinate PASRR assessments for residents with qualifying mental health diagnoses. A resident with bipolar disorder, a resident with schizophrenia, bipolar disorder, borderline personality disorder, and PTSD, and a resident with PTSD were not correctly referred for Level I PASRR screening, and staff acknowledged that the screenings were inaccurate or incomplete. The records also showed intact cognition for two residents and moderate cognitive impairment for one resident, along with psychotropic medication use for one resident.
A resident with bipolar disorder, schizophrenia, and psychotic symptoms was not referred for PASSR Level II review after a significant change in status. The MDS Coordinator said she received the PASSR Level-I screening but did not submit a new one, and the DON said she did not know the process to follow if the screening was inaccurate. The resident’s MDS did not include PASSR status, and the on-file Level-I screening incorrectly stated the resident did not have mental illness or dementia.
A resident with anxiety, PTSD, depression, moderately impaired cognition, and documented cognitive deficits with visual hallucinations had a PASARR I that indicated further evaluation was needed, but the clinical record lacked evidence that the PASARR Level II assessment was completed. The facility could not produce documentation that the Level II was requested or provided, and an Administrative Nurse stated social services could not find proof the assessment had been done.
A resident admitted with aphasia, hemiplegia and hemiparesis, and stimulant abuse later received new diagnoses of bipolar II disorder and anxiety disorder, but the facility did not complete a new PASRR Level I. The ADON stated the resident should have had a new PASRR when the new MH diagnoses were identified.
Missed Level II PASRR Request for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a Level II PASRR evaluation request to NC MUST for a resident with a serious mental illness. Resident #10 had been deemed Level I PASRR by the State and was admitted with diagnoses including dementia, depression, and anxiety. After a hospital stay, an updated FL-2 completed by the hospital physician added bipolar disorder to the resident’s diagnoses, and bipolar disorder was also added to the facility diagnosis list. The resident’s record showed orders for venlafaxine and buspirone for depression and anxiety, and the admission MDS coded the resident with bipolar disorder and antidepressant use, while also indicating the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness. There was no documentation that a Level II PASRR evaluation was completed when the bipolar disorder diagnosis was added. During interview, the Discharge Planning Director stated she was responsible for ensuring Level II PASRR evaluations were current and accurate, and said she missed the bipolar disorder diagnosis when it was added in 10/2025. She reported that she did not request the Level II PASRR evaluation or submit the FL-2 to NC MUST until 6/9/2026, after becoming aware of the need following a later hospital return, and uploaded clinical documents on 6/10/2026 to trigger the onsite Level II evaluation. The Administrator stated the Discharge Planning Director was responsible for submitting the requests and that the evaluation should have been done immediately when the diagnosis warranted screening.
PASRR Assessments Not Updated After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASRR assessments were updated after new mental health diagnoses were documented for two residents. For one resident, the admission record showed diagnoses including brief psychotic disorder and major depressive disorder, while the Florida AHCA PASRR dated 11/11/2025 did not document mental illness. Subsequent records included physician orders for quetiapine for brief psychosis and trazodone for insomnia related to depression, along with psychology notes listing adjustment disorder, major depressive disorder, and delusional disorders. The DON stated in interview that the resident was being monitored in March because he was having a hard time after learning his cancer had returned. For the second resident, the admission record showed diagnoses including major depressive disorder and anxiety disorder, but the Florida AHCA PASRR dated 10/24/2025 did not document any mental illness. Later behavioral health documentation identified a past psychiatric history of depression and assessed major depressive disorder, recurrent, unspecified, and a subsequent progress note documented treatment concerns related to condition decline and limiting behaviors. A later physician order for escitalopram was written for depression with monitoring for isolation and sadness. The Social Services Assistant stated both PASRRs needed to be updated, and the DON stated psychology provides Social Services a list of residents seen and attends meetings where resident changes are discussed.
Failure to Refer Residents With Mental Illness for PASRR Screening
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for residents with newly evident or possible serious mental disorders. Survey review found that Resident #67, Resident #48, and Resident #7 were not referred for a Level I PASRR screening when they had diagnoses of mental illness, and the facility’s PASRR process did not accurately reflect their qualifying conditions. Resident #67’s record showed diagnoses of bipolar disorder and depression, with an admission MDS indicating intact cognition and a PASRR I screening that showed no evidence or indicator of mental illness. During interview, the MDS Nurse stated the PASRR screening was inaccurate and needed to be redone and submitted to the local health authority. Resident #67 stated he had carried a bipolar disorder diagnosis since discharge from the military. The ADON stated the MDS Nurse was responsible for referring residents with mental illness for Level I PASRR screening. Resident #48’s record showed diagnoses including schizophrenia unspecified, bipolar disorder, borderline personality disorder, and PTSD, along with regular antipsychotic and antidepressant use and a BIMS score of 15. His PASRR Level I screening indicated evidence of mental illness, but the MDS Coordinator/RN stated she had inaccurately coded the screening and that his diagnoses were qualifying diagnoses that should have been referred for PASRR evaluation. Resident #7’s record showed PTSD, a prior PASRR Level I screening that did not identify mental illness, and an annual MDS showing moderate cognitive impairment. The MDS Coordinator/RN stated Resident #7 should have had another PASRR Level I screening and referral to the local authority. The facility policy stated that when a PASRR is filled out incorrectly, the MDS coordinator will contact the corresponding case worker to correct the form.
Failure to Refer Resident With Mental Illness for PASSR Level II Review
Penalty
Summary
The facility failed to refer a resident with mental illness for Level II resident review after a significant change in status assessment. Resident #12’s quarterly MDS assessment documented a BIMS score of 8, indicating moderately impaired cognitive skills for daily decision making, and listed diagnoses of bipolar disorder and schizophrenia. The resident’s comprehensive care plan also identified unspecified psychosis, schizoaffective disorder, and bipolar disorder, with a note that the resident could see and hear people in her room trying to rape her. However, the MDS did not include PASSR status, and the resident’s PASSR Level-I screening on file stated that she did not have mental illness and did not have dementia. During interview, the MDS Coordinator said she received the resident’s PASSR Level-I screening and did not submit a new one. She stated she was not supposed to correct the PASSR Level-I screening and did not know the effect it could have on the resident if it was incorrect. The DON said PASSR was data entry and that she reviewed Level-I screenings to ensure they were entered correctly in SIMPLE, but she did not know the process to follow if the Level-I screening was inaccurate. The facility policy stated that the Level I screen should be reviewed at least quarterly and that the appropriate state designated agency should be contacted for any resident requiring a Level II screen upon learning of an SMI/ID diagnosis that was previously unknown or undetermined.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to coordinate care for a resident following a Preadmission Screening and Resident Review (PASARR) that indicated a Level II evaluation was needed. The resident had diagnoses of anxiety, PTSD, and depression, and the Quarterly MDS documented a BIMS score of 9, indicating moderately impaired cognition. The resident’s CAA also documented a cognitive deficit and visual hallucinations, and the care plan included interventions for family involvement, activities, social interaction, and in-room activities. The resident’s EMR contained a PASARR I dated 09/11/24 that indicated further evaluation was required, but the clinical record lacked evidence that the PASARR Level II evaluation was completed. When the facility was asked for evidence that the Level II assessment had been requested and provided, it was unable to produce documentation. On observation, the resident was seen sitting in the dining room with a smoker apron on, watching TV, and her hair was oily and stringy. The Administrative Nurse stated the social service department was unable to find documentation that the Level II PASARR assessment had been completed as indicated.
Failure to Complete PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a PASRR was completed when new mental health diagnoses were identified for Resident #4. The resident was admitted with diagnoses including aphasia, hemiplegia and hemiparesis, and stimulant abuse, and the medical record later documented new diagnoses of bipolar II disorder and anxiety disorder. Appendix PP of the State Operations Manual states that any resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition must be referred to the appropriate state-designated authority for review. During interview, the ADON stated that Resident #4 should have had a new PASRR Level I completed when the bipolar II disorder and anxiety disorder diagnoses were made.
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