Failure to Request Level II PASRR Evaluation for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident admitted with multiple mental health diagnoses. Documentation showed the resident had a Level I PASRR determination with no expiration date and was admitted with schizoaffective disorder, anxiety, depression, and bipolar disorder. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, yet listed active psychiatric/mood disorder diagnoses including anxiety, depression, bipolar disorder, and schizophrenia, and the resident was receiving antianxiety medications. Subsequent psychiatric nurse practitioner notes documented a history of obsessive compulsive disorder (OCD), schizophrenia, bipolar disorder, major depressive disorder, schizoaffective disorder, anxiety, and insomnia, and ongoing treatment for anxiety, depression, and bipolar disorder. Despite these documented mental health conditions and ongoing psychiatric treatment, there was no evidence that the facility submitted a request for an updated Level II PASRR evaluation for this resident. The social worker reported that her process was to review diagnoses and medications for new admissions and submit to the North Carolina Medicaid Uniform Screening Tool (NCMUST) when a resident had a mental health diagnosis, and that she had many Level II PASRRs at the facility and a PASRR office contact for questions. She stated she had conducted an audit when she started in August 2025 and acknowledged that this resident was overlooked. The administrator stated that the expectation was for the social worker to review all residents admitted with a Level I PASRR and a mental health diagnosis and submit them for re-evaluation for a Level II PASRR, which did not occur for this resident.
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