Failure to Accurately Complete PASRR Screenings and Level II Referrals for Multiple Residents With Mental Disorders
Summary
The deficiency involves the facility’s failure to ensure accurate completion, updating, and referral of PASRR Level I screenings and Level II evaluations for multiple residents with serious mental illness (SMI) or other mental disorders. For one resident with borderline personality disorder, PTSD, recurrent depression, anxiety disorders, and factitious disorder, hospital-generated PASRRs repeatedly documented “no” history of SMI, mental disorders, or psychotropic medications, despite extensive behavioral health diagnoses and active psychotropic orders. The facility did not correct these PASRRs or complete a Level I PASRR after the 30‑day convalescent period ended, even though the resident’s MDS assessments, psychiatric notes, care plans, and social services assessments consistently documented anxiety, depression, PTSD, borderline personality disorder, and ongoing psychiatric treatment. Another resident with PTSD, depression, generalized anxiety disorder, bipolar disorder, polysubstance abuse, and recent inpatient psychiatric hospitalization for suicidal ideation had a PASRR Level I that omitted major depression and bipolar disorder and incorrectly indicated no recent psychiatric hospitalization or suicidal ideation. A subsequent PASRR Level I, completed after re‑admission, documented bipolar disorder and anxiety disorder but again indicated no recent psychiatric hospitalization or suicidal ideation and concluded that no Level II referral was necessary. The clinical record showed no evidence of any PASRR Level II referral for this resident. A separate resident with diabetes, depression, and later‑added bipolar disorder exhibited altered mental status and psychotic‑like behavior, prompting a psychiatric consult. However, the quarterly MDS did not list bipolar disorder as an active diagnosis, and the PASRR Level I documented major and mild/situational depression but stated the resident did not have bipolar disorder and did not require a Level II referral, with no Level II referral found in the record. For another resident admitted and re‑admitted with anxiety disorder, schizophrenia, recurrent depressive disorder, chronic PTSD, and polysubstance abuse in remission, multiple PASRR Level I tools were inconsistent with the clinical record. One hospital PASRR identified bipolar disorder and personality disorder and psychotropic use but did not document whether a Level II referral was needed. A subsequent facility PASRR Level I documented schizophrenia and anxiety disorder but stated the resident was not prescribed psychotropic medications, despite the admission MDS showing active anxiety, depression, schizophrenia, and use of antianxiety, antidepressant, antipsychotic, and anticonvulsant medications. A later PASRR Level I listed schizophrenia only, omitted depression, anxiety, and other mental disorders, and left the Level II referral determination section blank, even though the same form listed multiple psychotropic medications for depression, anxiety, and schizophrenia. No Level II referral was present in the record. Additional residents with multiple psychiatric diagnoses and psychotropic treatment also lacked accurate PASRR documentation and appropriate Level II referrals. One resident with anxiety disorder, bipolar disorder (current episode depressed), and schizophrenia had a PASRR Level I that correctly listed these diagnoses and related psychotropic medications but indicated no Level II referral; a later PASRR for the same resident omitted all mental illness diagnoses and psychotropic medications, again indicating no Level II referral, despite MDS documentation of anxiety disorder, bipolar disorder, schizophrenia, and use of antipsychotics and antidepressants. Another resident with aphasia, anxiety disorder, recurrent depressive disorder, mood disorder, personality and behavioral disorder due to physiological condition, and adjustment disorder had an initial PASRR listing anxiety and depression with no Level II referral, followed by a second PASRR that omitted all diagnoses and psychotropic medications, again indicating no Level II referral, despite orders and care plans for Depakote and anticonvulsant therapy for mood disorder. In interviews, the Director of Social Services acknowledged that PASRRs were inaccurate or incomplete, that required Level II referrals had not been submitted for several residents, that the facility was responsible for ensuring PASRR accuracy, and that she was uncertain about PASRR update requirements and tracking for residents needing Level II evaluations. The Director of Social Services further stated that the facility’s process for identifying residents with mental disorders or intellectual disabilities involved review of diagnoses such as depression, anxiety, bipolar disorder, and schizophrenia, and review of psychiatric medications, and that residents with more than one or two psychiatric diagnoses and stays longer than 30 days should automatically have a Level II PASRR referral submitted. She confirmed that she was responsible for completing Level I PASRRs and submitting Level II referrals, that PASRR resource reviews were infrequent and random, and that she had not received formal performance evaluation or sufficient training to identify knowledge gaps. She also stated that inaccurate or incomplete PASRR screening and referral processes could result in residents not receiving the services they need, and that accurate PASRR completion is critical to resident safety and quality of care.
Penalty
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PASARR screening was inaccurate for two residents. One resident had bipolar disorder and a Level I PASARR showing a need for Level II review, but the required Level II evaluation was not obtained before or after admission. Another resident was admitted with major depressive disorder, personality disorder, substance abuse, and PTSD, and the Level I PASARR also indicated a Level II evaluation was required prior to admission; the DON later confirmed the PASARR was incorrect and should have been caught on admission and during audit review.
A resident with severe cognitive impairment, dementia, Alzheimer's disease, depression, anxiety, and psychotic disorder had an inaccurate PASRR PL1 screening that marked mental illness as no and identified dementia as the primary dx. The MDS Nurse stated she was responsible for reviewing PASRR screenings against hospital paperwork for accuracy, and the DON and Administrator acknowledged that inaccurate PASRR screenings could affect resident services.
A resident with rhabdomyolysis, CKD, and HTN was admitted after a Level I PASRR screen identified serious mental illness and an intellectual disability, but the required Level II determination was not completed before admission. Records showed the resident was later found to need an abbreviated Level II assessment, and staff confirmed the Level II review should have been obtained prior to admission.
A resident admitted with PTSD and depression had a PASRR Level I screening submitted by the hospital that did not include those diagnoses, and the facility did not submit an updated PASRR request with all of the resident’s mental health diagnoses. The DTRS stated he was responsible for PASRR submissions but had not verified the screening details, and the Administrator stated the PASRR request should have included PTSD and depression at admission.
PASRR screening was not properly completed for two residents with mental health diagnoses. The Level I PASRRs did not include active diagnoses such as depression, anxiety, delusional disorder, and PTSD, and no Level II PASRR evaluations were found in either record. Both residents were cognitively intact, had no behaviors or rejections of care, and were receiving anti-anxiety and anti-depressant medications.
PASRR screening was not appropriately completed for a resident with severe cognitive impairment, documented hallucinations, MDD, and psychotropic medication use. The PASRR did not include the resident’s hallucinations or depression diagnosis, and the SW confirmed it had not been updated with those findings.
Inaccurate PASARR Screening and Missing Level II Evaluation
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was inaccurate for 2 of 2 residents reviewed. One resident was admitted with a Level I PASARR dated 10/27/23 that identified bipolar disorder, receipt of mental illness services, and a need for a Level II PASARR evaluation for serious mental illness, but there was no evidence the required Level II evaluation and determination were obtained before admission or afterward. The facility did not initiate action to obtain the Level II PASARR until the survey process on 8/12/26, and the DON stated the admissions team and social services were responsible for review while audits were in place. A second resident was admitted with diagnoses including major depressive disorder, personality disorder, psychoactive substance abuse, and PTSD, and had care plan concerns for communication difficulty, altered mood and behaviors, physical and verbal aggression, and gender identity-related behaviors. The resident's Level I PASARR completed on 07/09/2026 indicated previous services for mental illness issues and stated that a Level II PASARR evaluation had to be completed prior to admission. During interview, the DON stated she completes and reviews PASARRs on admission, and after reviewing this resident's Level I PASARR, confirmed it was incorrect and should have been identified on admission and during audit review, with a Level II PASARR evaluation needing to be initiated.
Inaccurate PASRR Screening for Resident With Dementia and Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for one resident reviewed for PASARR accuracy. The resident was admitted and re-admitted to the facility, was not his own responsible party, and had diagnoses including major depressive disorder, Alzheimer's disease, dementia, and anxiety disorder. His quarterly MDS reflected a BIMS score of 00, indicating severe cognitive impairment, and he was documented with active diagnoses of Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. His care plan also documented behaviors including physical aggression related to dementia/confusion and use of antidepressant medication related to depression. The resident's PASRR Level 1 Screening, completed at the incoming nursing facility, identified dementia as the primary diagnosis and marked mental illness as no. However, the resident's electronic medical record did not contain a Mental Illness/Dementia Resident Review form 1012. During observation, the resident was lying in bed, oriented only to identity, and disoriented to place, time, and situation; he was unable to respond to interview questions because his cognition was severely impaired. During interview, the MDS Nurse stated she was responsible for PASARR screening for mental disorders and intellectual disabilities and that PASRR Level 1 screenings must be accurate when received from the incoming facility. She stated she checks the PL1 screening against hospital paperwork to confirm accuracy and acknowledged that inaccurate screenings could leave residents without extra services they need or qualify for. The DON and Administrator also stated that inaccurate PASRR screenings could affect services provided to residents, and the Administrator stated the MDS Nurse should have reviewed diagnoses when reviewing PASARR screenings provided by the hospitals.
PASRR Level II Not Completed Before Admission
Penalty
Summary
The facility failed to ensure that a resident was screened for a mental disorder or intellectual disability before admission. Resident #373 was admitted with diagnoses including rhabdomyolysis, chronic kidney disease, and hypertension. The resident’s MDS documented that the resident was admitted from an acute hospital, was considered by the state PASRR Level II process to have a serious mental health and/or intellectual disability, and had an intellectual disability. The record showed that the Level I Review on the SCREEN DOH-695 form identified the resident as having a serious mental illness and a diagnosis or documented history of mental retardation and/or developmental disability, with a categorical determination of convalescent care. An OPWDD PASRR Level II Referral Response Letter later stated that an abbreviated Level II Assessment was required and that the categorical determination was convalescent care, not to exceed 120 days, with need for specialized services and nursing facility level of care. There was no documented evidence that the required PASRR Level II Assessment with determination and recommendation was completed prior to the resident’s admission to the facility. Staff interviews confirmed that the Level I screen had been completed in the hospital and that the Level II determination should have been obtained before admission, but the Level II determination was completed after the resident had already been admitted. The Facility Administrator stated the determination should have been received before admission, including when the referral was received on a weekday and the resident was admitted on the weekend.
PASRR Screening Missing Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a request for an updated PASRR evaluation for a resident admitted with diagnoses including PTSD and depression. A PASRR Determination Notification letter showed the resident had a Level I PASRR with no expiration date, and the facility provided a North Carolina PASRR Level I screening form that had been submitted by the hospital Social Worker on 9/29/25 but did not include the diagnoses of PTSD or depression. The resident’s admission record showed diagnoses that included depression and PTSD, and the admission MDS indicated she was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. The MDS also showed active psychiatric/mood disorder diagnoses of PTSD and depression, and that she received an antidepressant during the assessment period. During interviews, the Director of Transitional Services stated he was responsible for submitting PASRR requests, had not verified the diagnoses included in the hospital screening, and should have ensured all mental health diagnoses were included. The Administrator stated the Director of Transitional Services should have submitted a PASRR request with all diagnoses, including PTSD and depression, when the resident was admitted.
PASRR Screening Not Completed for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASRR screening was completed for two residents with diagnoses of serious mental illness. For Resident #80, the Level I PASRR completed on 11/05/19 did not include active diagnoses of major depressive disorder, anxiety disorder, and delusional disorder, and the determination letter stated the resident did not meet the federal definition for mental illness. The resident was admitted with those diagnoses, and the record contained no evidence that a Level II PASRR evaluation was completed. The annual MDS showed the resident was cognitively intact, had no behaviors or rejections of care, and was receiving anti-anxiety and anti-depressant medications. For Resident #87, the Level I PASRR completed on 3/23/23 did not include the resident’s active diagnosis of PTSD, and the determination letter stated the resident did not meet the federal definition for mental illness. The resident was admitted with PTSD, and the record contained no evidence that a Level II PASRR evaluation was completed. The admission MDS showed the resident was cognitively intact, had no behaviors or rejections of care, and was receiving anti-anxiety and anti-depressant medications. The Director of Social Services stated the former Director of Social Services should have completed new Level I PASRR screens for both residents and submitted them for review.
PASRR Not Updated With Documented Mental Health Findings
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not appropriately completed for one resident reviewed. The resident’s MDS showed a BIMS score of 3, indicating severe cognitive impairment, and documented a diagnosis of cognitive impairment. The clinical record also showed psychotic symptoms, including hallucinations, and prescriptions for psychotropic medications including Risperdal, Trazodone, and Depakote. The resident’s comprehensive care plan documented a history of feeling down/depressed/hopeless, a diagnosis of Major Depressive Disorder, and a psychiatry evaluation. However, the resident’s PASRR dated June 3, 2025 did not include the documented hallucinations or the diagnosis of major depressive disorder. During interview, the social worker confirmed the PASRR had not been updated with the resident’s hallucinations or depression diagnosis.
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