Failure to Update PASRR After New Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Preadmission Screening and Resident Review (PASRR) for a resident with mental health diagnoses. The facility’s policy, revised 02/16/24, required the Social Worker or designated staff to assure that all patients with mental disorders or intellectual disability receive appropriate pre-admission screenings according to federal and state regulations, and that if a PASRR was not completed or was incorrect, Social Services would coordinate with the appropriate agency, review PASRR results, and incorporate recommendations into the assessment and care plan. Record review showed that the resident was admitted on a specified date and later diagnosed with Major Depression and Generalized Anxiety Disorder. Despite these diagnoses, the resident’s PASRR Level I Identification Screening, dated 12/10/25, documented that the resident did not have a diagnosis of or suspected mental illness. During interview, the Social Worker stated that the resident was diagnosed with depression and anxiety on 12/11/25 after admission and acknowledged that the PASRR should have been revised to reflect the current diagnoses. In a separate interview, the Administrator stated it was her expectation that the PASRR would have been revised with the new diagnosis. The failure to update the PASRR to reflect the resident’s mental health conditions constituted the cited deficiency.
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