Failure to Integrate PASRR Level II Determination Into MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to incorporate a resident’s Level II PASRR determination into the MDS assessments and to coordinate this information with the interdisciplinary team. One resident with a diagnosis of PTSD was admitted to the facility and had both a comprehensive and a quarterly MDS assessment completed, each indicating that no PASRR Level II had been done. However, record review showed that the resident had, in fact, undergone a PASRR Level II review by the state’s contracted PASRR service, which approved a 180‑day stay with a specified end date. This PASRR Level II information was not reflected in the MDS, despite the facility’s admission policy requiring PASRR pre‑admission screening and approval for the appropriate level of care prior to admission. Interviews with staff revealed that there was no established process to ensure that completed PASRR Level II determinations were communicated to the RN/MDS coordinator or incorporated into the MDS. The social worker reported that she completed PASRR forms, kept them in her office, and did not share the completed PASRR documentation with the interdisciplinary team or the RN/MDS coordinator, stating that it did not occur to her that she needed to inform the MDS coordinator whether a resident was PASRR Level I or II. She indicated she only informed nursing of any PASRR recommendations and noted she had MDS permissions only for Section S. The RN/MDS coordinator confirmed there was no process to determine whether a PASRR Level II had been completed and that Section S does not trigger Section A of the MDS, and she was unaware that the social worker completed PASRR Level II reviews for residents.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.