Inaccurate PASRR Level I Primary Diagnosis Documentation
Penalty
Summary
The facility failed to ensure that a resident’s Preadmission Screening and Resident Review (PASRR) accurately reflected the resident’s primary diagnosis, resulting in an incorrect PASRR Level I determination. The resident was admitted with multiple diagnoses, including major depressive disorder, anxiety disorder, and alcohol dependence, and record review showed the primary diagnosis was recurrent major depressive disorder. However, the PASRR Level I, dated 9/9/25, documented “Yes” in Box 12, indicating the individual had a primary diagnosis of dementia or Alzheimer’s disease. During an interview on 3/5/26 at 4:45 PM, the Social Worker confirmed that this PASRR Level I had been inaccurately completed. This inaccuracy was identified through record review and staff interview, which showed a discrepancy between the documented primary diagnosis in the medical record and the diagnosis selected on the PASRR Level I form.
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