Failure to Complete Timely PASRR Level I and II Evaluations for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely completion of PASRR (Preadmission Screening/Annual Resident Review) Level I and Level II evaluations for a resident with serious mental illness. The resident was a female with diagnoses including paranoid schizophrenia, dementia, and cognitive communication deficit. Her care plan, revised on 6/14/25, identified a behavior concern related to paranoid schizophrenia, noting that she might be paranoid about money and others’ opinions, potentially leading her to intrude on others’ privacy. Interventions included assisting her to develop appropriate coping and interaction methods, encouraging appropriate expression of feelings, anticipating and meeting needs, obtaining behavioral health consults as needed, and administering and monitoring psychotropic medications. Record review showed a Level II evaluation letter dated 1/5/25 stating that the resident could continue to reside in the nursing facility and may choose to receive specialized mental health/developmental disability services, with specialized services to be planned by the local community mental health agency. The letter indicated that a subsequent Level II evaluation would need to be completed by 1/4/26. During an interview, the Social Services Director reported that the Level II evaluation due by 1/4/26 was not available and that she was unsure whether the OBRA evaluator, who had been in the facility on 2/19/26, had seen this resident. She also stated that Level I evaluations were completed yearly and with changes in condition. Electronic correspondence from the Nursing Home Administrator confirmed that a Level I was completed on 12/5/24 and a Level II on 1/5/25, but there was no Level I documented for 2025, demonstrating that required PASRR evaluations were not completed timely for this resident.
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