Failure to Resubmit and Update PASRR for Residents With Mental Illness and Psychiatric Hospitalizations
Summary
The deficiency involves the facility’s failure to ensure required Preadmission Screening and Resident Review (PASRR) Level II evaluations and resubmissions for residents with identified or newly diagnosed mental illness, and for residents experiencing significant changes such as psychiatric hospitalization. For one resident, the clinical record showed admission with diagnoses including traumatic subdural hemorrhage, anxiety disorder, irritability and anger, and major depressive disorder. The resident’s PASRR Level I form, dated prior to admission, did not list any mental health diagnoses, despite the medical record and MAR documenting treatment with Seroquel and Sertraline for major depressive disorder, with the diagnosis onset and medication start dates clearly recorded. The DON confirmed that the admitting diagnoses included major depressive disorder, and care plan and IOP assessments documented depression, anxiety, hallucinations, delusions, withdrawal, and mood swings. Further review showed that this same resident’s PASRR Level I (142 form) approval date was more than 30 days before the actual admission date, and the resident had been discharged from the facility for more than 30 days before returning, which staff acknowledged should have triggered a new PASRR. Interviews with the social worker, MDS staff, and DON confirmed that no new PASRR was completed upon the resident’s return, despite the extended absence and subsequent significant changes, including a PEC (Physician’s Emergency Certificate) event and increased psychotropic medications. The DON and administrator also verified that they were not aware that a Resident Review form and PASRR review were required after such significant changes or the addition of IOP services. For another resident, the clinical record showed admission without psychiatric diagnoses initially, but later documentation reflected a diagnosis of major depressive disorder. The resident’s original Level I PASRR, completed by a local hospital, did not list any mental illness in the mental illness section. The social worker confirmed that there was no process to identify residents with new mental illness diagnoses who required a resubmitted Level I PASRR for possible Level II evaluation and stated she was unaware that resubmission was required after a new psychiatric diagnosis. This resident also had an unplanned discharge to an inpatient psychiatric facility under a PEC for escalating agitation and threatening behaviors, with documentation of severe major depressive disorder and increased Abilify for uncontrolled symptoms. Despite this inpatient psychiatric admission and diagnosis, there was no evidence of any subsequent Level I PASRR resubmission, and both the social worker and DON confirmed that the PASRR had not been updated and that there was no process in place to review PASRRs for accuracy when such events occurred.
Penalty
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PASRR was not updated for a resident reviewed for behavioral services after a psychology evaluation documented major depressive disorder, recurrent, moderate, with symptoms of depressed mood, sleep disturbance, fatigue, and appetite changes. The DON stated the PASRR should have reflected depression and that Balance Wellbeing would update it, while the existing PASRR did not document any mental or suspect mental illness.
Failure to notify the county SMHA for a resident with new mental health diagnoses. The resident’s MDS showed bi-polar disorder, PTSD, and personality disorder, while the PAS only documented bi-polar disorder at admission. PTSD and personality disorder were added after admission, but the SSD said she only checks the PAS for level II PASARR needs and does not review for new diagnoses or know that SMHA contact may be needed for mental health services.
Failure to coordinate PASRR services and document required meetings affected three residents with IDD or related conditions. One resident with spina bifida and IDD had no documented annual PCSP meeting in the prior year, another resident with mild intellectual disabilities and mental health diagnoses had no documentation of quarterly PASRR PCSP meetings, and a third resident with IDD had no documentation of habilitation coordination or independent living skills training notes despite those services being recommended. Interviews confirmed the facility lacked a system to track the coordinator’s visits and required PASRR meeting documentation.
A resident who was PASRR positive related to IDD had a care plan calling for coordination of specialized services, but the facility did not incorporate PASRR recommendations into assessment, care planning, or transitions of care. A PCSP showed OT and PT were newly requested and agreed upon at a quarterly meeting, yet the LTC portal had no record of a specialized services request for therapy afterward. Staff interviews showed the MDS Coordinator, former MDS Coordinator, Habilitation Coordinator, and DON were unaware of or not trained on the PASRR requirements tied to the requested services.
PASRR Level II Evaluation Not Completed Timely: A resident with PTSD and GAD had a PASRR Level I screening that identified the need for a Level II eval, but the required review was not completed when the resident was admitted. The SSD acknowledged the PASRR process was not completed as required and stated the omission was later identified during a chart update.
PASRR Not Updated for New Mental Health Diagnoses: A resident with existing mental health diagnoses later developed PTSD and Major Depressive Disorder, but the facility did not update the PASRR or submit it for Level II review. The PASRR had listed anxiety, depression, and auditory hallucinations, and staff confirmed it needed to be updated after the new diagnoses were identified.
PASRR Not Updated for Resident With Depression
Penalty
Summary
The facility failed to update the State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) for one resident who was reviewed for behavioral services. The resident was admitted with diagnoses including Major Depressive Disorder, and the PASRR dated 8/28/2025 did not document any mental or suspect mental illness. A Balance Wellbeing Psychology Evaluation Note dated 5/6/2026 documented a chief complaint of depression and described the resident as having major depressive disorder, recurrent, moderate, with symptoms including decreased interest in activities, persistent depressed mood, sleep disturbances, fatigue, and changes in appetite occurring on more than half of the days. During an interview, the DON stated the resident's PASRR should have been updated to reflect depression and that Balance Wellbeing would be the ones to update it. The facility policy titled Resident Assessment-Coordination with PASARR Program states the facility coordinates assessments with the PASARR program for individuals with mental disorder, intellectual disability, or a related condition.
Failure to Notify SMHA for New Mental Health Diagnoses
Penalty
Summary
The facility failed to notify the county designated State Mental Health Authority (SMHA) for 1 of 5 residents, who had a new onset of mental illness. The resident’s comprehensive MDS assessment accepted on 4/22/26 identified diagnoses of bi-polar disorder, PTSD, and personality disorder, with cognition intact and no behaviors displayed during the assessment period. The resident’s PAS completed on 5/24/24 documented a current diagnosis of bi-polar disorder, but did not mention PTSD or personality disorder at that time. The diagnosis list showed PTSD was added on 5/28/24 and personality disorder on 6/24/25, both after admission. During interview on 7/7/26, the social service designee stated she only glances at the PAS for new admissions to determine whether a level II PASARR is required, does not check for new diagnoses after admission, and was not aware the SMHA needed to be contacted to determine whether mental health services would be required. A policy was requested, but none was provided during the survey period.
Failure to Coordinate PASRR Meetings and Document Specialized Services
Penalty
Summary
The facility failed to coordinate with the appropriate State-designated authority for residents with mental disorder, intellectual disability, or related conditions, as reflected in three resident records reviewed for PASRR assessments and services. Resident #6 had diagnoses including spina bifida and IDD, required assistance with multiple activities of daily living, and had a care plan that included specialized services such as habilitation coordination, independent living skills training, behavioral support, and specialized OT. Her PASRR records showed IDD, but the medical record did not indicate that an annual PCSP meeting occurred in 2025; the last meeting documented was 10/23/24. Resident #31 had diagnoses including mild intellectual disabilities, major depressive disorder, anxiety, and mixed obsessional thoughts and acts. Her annual MDS indicated moderate cognitive loss and that she was considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Her care plan stated she was PASRR positive for intellectual disabilities and that PASRR PCSP meetings were to be held with the LMHA and RP at least quarterly, but the EMR contained no documentation of quarterly PASRR PCSP meetings held in 2025. Resident #5 had diagnoses including intellectual disability and developmental disorder of scholastic skills, with a BIMS score of 9 indicating moderate cognitive impairment. His care plan identified him as PASRR positive for IDD and included habilitation and specialized services, and a PCSP meeting documented that habilitation coordination and independent living skills services were recommended. However, the EMR contained no documentation of habilitation coordination or independent living skills training notes. Interviews with the Habilitation Coordinator, MDS Coordinator, DON, Director of IDD Service, and Administrator confirmed there was no documentation after monthly visits, that the facility was not aware of when the coordinator visited, and that there was no system in place to monitor oversight or ensure the required annual and quarterly meetings were held.
PASRR Services Not Incorporated Into Resident Assessment and Care Planning
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR evaluation report into the assessment, care planning, and transitions of care for one resident who was PASRR positive related to IDD. The resident’s record showed diagnoses of schizoaffective disorder, bipolar type, and major depressive disorder, and a quarterly MDS assessment documented severe impairment in thinking with a BIMS score of 2. The care plan dated 10/17/2024 identified the resident as PASRR positive and included coordination of specialized services provided by the Local Authority. A PASRR Comprehensive Service Plan dated 12/10/2025 showed a quarterly meeting in which Medicaid eligibility was confirmed and OT and PT were new specialized services requested, with LA comments indicating all services were discussed and agreed upon. However, the LTC online portal had no record of a specialized services request for therapy after that meeting or any other meetings in the portal after that date. During interviews, the former MDS Coordinator, current MDS Coordinator, Habilitation Coordinator, and DON each described their roles and stated they were unaware of or not trained on the PASRR requirements related to the requested therapy services.
PASRR Level II Evaluation Not Completed Timely
Penalty
Summary
The facility failed to ensure compliance with PASRR requirements for RI #5 by not completing the required PASRR Level II Evaluation after the Level I screening identified the need for it. RI #5 was admitted with diagnoses of PTSD and Generalized Anxiety Disorder. The PASRR Level I Determination dated 11/07/2024 documented that, after QA review, the resident required a Level II Evaluation because of serious mental illness diagnoses, including PTSD and Generalized Anxiety Disorder, and also stated the resident met criteria for a categorical determination for convalescent care and could be admitted while the Level II Evaluation was completed. The Level I Determination further stated that the admitting nursing facility was required to report the admission to the OBRA PASRR Office at the time of admission to begin the Level II process and determine eligibility for specialized services. During interview, the SSD stated the Level I screening had been completed prior to admission, but the required Level II evaluation had not been completed at that time. She stated she did not recall whether the resident had been admitted under emergency admission or exempted hospital discharge, acknowledged responsibility for ensuring the PASRR process was completed, and stated the omission was identified during a chart update when the Level I PASRR screening was redone. She stated the Level II PASRR evaluation was completed later.
PASRR Not Updated for New Mental Health Diagnoses
Penalty
Summary
The Pre-admission Screening and Resident Review (PASRR) was not updated for a resident after new mental health diagnoses of Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder were identified during the stay. The resident had been admitted with mental health-related diagnoses including auditory hallucinations and anxiety disorder, and a physician determined the resident did not have decision-making capability for health care decisions. The resident’s PASRR was most recently completed by the facility and listed anxiety, depression, and auditory hallucinations under current diagnoses. After the resident later acquired PTSD and Major Depressive Disorder, the PASRR was not updated and submitted for Level II review. During interview, the NHA stated the PASRR was usually completed by either the Director of Admissions or the Director of Social Services, and both the Director of Admissions and the Director of Social Services confirmed the PASRR needed to be updated for the new diagnoses.
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