Inaccurate PASARR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of Preadmission Screening and Resident Review (PASARR) Level I screenings for multiple residents with documented mental health diagnoses. Record review showed that several residents were admitted with diagnoses such as major depressive disorder, depression, and anxiety disorders, yet their PASARR Level I forms indicated that they did not have mood, anxiety, or other qualifying mental health conditions. For example, one resident admitted with major depressive disorder had a PASARR Level I dated the same day of admission that documented no mood, panic, anxiety, personality, psychotic, depression, or substance-related disorders. Similar discrepancies were identified for additional residents. Another resident admitted with major depressive disorder had a PASARR Level I completed the day prior to admission that incorrectly indicated no mood or depression-related diagnoses. Residents with documented anxiety disorders also had PASARR Level I screenings that stated they did not have anxiety, mood, or related mental health conditions. Multiple residents with diagnoses of depression or major depressive disorder had PASARR Level I screenings completed on or near their admission dates that failed to acknowledge these conditions, instead marking that no such mental health diagnoses were present. During an interview, the Social Services Director reported that the facility did not have a systematic process in place to review incoming PASARRs as part of the admission screening process. The Social Services Director stated she had only recently been informed that reviewing resident PASARRs was the responsibility of her department and acknowledged that PASARRs were not being reviewed for accuracy. She confirmed that the PASARRs for all identified residents were inaccurate and stated that they should have reflected the residents’ documented mental health diagnoses.
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