Failure to Include Bipolar Disorder Diagnosis on PASRR Level I Evaluation
Penalty
Summary
The facility failed to ensure that a resident with an identified mental health diagnosis was accurately referred for a PASRR Level II evaluation, resulting in an incomplete PASRR Level I form. The resident was initially admitted with documented diagnoses of Bipolar Disorder, Depression, and Anxiety Disorder, and later readmitted with the same conditions. However, review of the PASRR Level I form completed on 07/30/2025 showed that only Major Depression and Anxiety Disorder were listed, and the Bipolar Disorder diagnosis was omitted. The LPN who completed the PASRR Level I form stated she relied solely on clinical records from the referring hospice agency, which did not list Bipolar Disorder, and did not review the resident’s initial admission records because she did not have access to them at that time. Upon later review of the initial admission clinical records, both the LPN and the quality improvement staff member confirmed that Bipolar Disorder had been an established diagnosis and should have been included on the PASRR Level I form but was not.
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