Failure to Submit Required PASRR Level II Evaluation
Penalty
Summary
Surveyors found that the facility failed to provide a PASRR Level II to the designated state agency for one resident whose record was reviewed for PASRR documentation. The facility’s PASRR Process policy, revised 8/29/25, stated that a positive PASRR Level I requires an in-depth evaluation by the state-designated authority (PASRR Level II) and that recommendations from the Level II determination must be incorporated into the person-centered care plan. Resident #7 was admitted with multiple diagnoses, including dementia and PTSD. A PASRR Level I dated 8/13/25 documented these diagnoses and referred the resident for further evaluation through a PASRR Level II, but when surveyors requested a copy of the PASRR Level II on 2/19/26, the facility was unable to provide it. The Medical Records Manager, who stated she was responsible for completing residents’ PASRRs, reported she had been instructed to submit a PASRR Level II only if psychiatric medications were listed and confirmed that Resident #7’s PASRR Level I should have been forwarded for a Level II review. This failure to follow the facility’s PASRR policy and to submit the required PASRR Level II for the resident with dementia and PTSD led to the cited deficiency related to coordination of assessments with the pre-admission screening and resident review program and referral for services as needed.
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