Failure to Obtain Updated PASRR Level II After Short-Term Approval Expired
Penalty
Summary
The facility failed to obtain a new PASRR Level II evaluation after a resident’s prior short‑term Level II approval expired. The resident’s face sheet documented diagnoses including schizophrenia, bipolar disorder, and depressive episodes, and a prior “Notice of PASRR Level II Outcome” showed a determination of short‑term approval without specialized services, which ended on a specified date. At the time of survey, when the surveyor requested an updated PASRR, the Admissions Director stated that the facility’s protocol for an expired Level II PASRR is to resubmit for screening and reported that the resident had been resubmitted and again flagged as requiring a Level II evaluation. However, the only documentation provided was a PASRR Level I Screen Outcome generated at the time of the survey, and there was no evidence of any PASRR submission between the expiration date of the short‑term approval and the start of the survey. The facility’s written policy addressed preadmission screening for individuals with mental disorders or intellectual disabilities but did not include procedures related to short‑term PASRR approvals. This resulted in the resident with documented serious mental health diagnoses remaining in the facility after the expiration of the short‑term PASRR Level II approval without a timely new Level II determination as required.
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