F0644

D

Failure to Initiate Required Level II PASRR Referrals After New Mental Health Diagnoses

Seaford, Delaware Survey Completed on 09-09-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to initiate required referrals for Level II PASRR screenings after new mental health diagnoses were identified for three residents. One resident had a PASRR Level I outcome listing major depression and suspected anxiety disorder, and was later admitted with bipolar disorder, anxiety disorder, and depression. The resident’s care plan and psychiatric evaluation documented depressed mood and multiple psychotropic medications for depression, and the active diagnoses and MDS assessments reflected bipolar disorder and depression. The Quality Manager and Social Worker Director both confirmed that this resident required a Level II PASRR referral due to the new onset of depression and bipolar disorder, and acknowledged that the referral was not completed.

Another resident was admitted with generalized anxiety disorder and had a PASRR Level I outcome listing anxiety disorder, but later had a new diagnosis of major depressive disorder documented in the admission record, care plan revisions addressing mood, and a significant change MDS reflecting active major depressive disorder. The Quality Manager and Social Worker Director confirmed that a Level II PASRR referral was required for this new diagnosis and that it was not done. A third resident, admitted several years earlier, had a new diagnosis of depression entered in the electronic chart and reflected on a quarterly MDS. The social worker reported she did not have access to the electronic system to place a PASRR Level II referral and confirmed that no Level II PASRR was completed. The Quality Manager also confirmed that no Level II PASRR had been completed in response to this new diagnosis of depression, and these findings were reviewed with the Nursing Home Administrator and Quality Manager at exit.