Failure to Complete Required PASRR Level 2 Referral Before Admission
Penalty
Summary
Surveyors found that the facility failed to follow required Pre-admission Screening and Resident Review (PASRR) procedures for one resident with intellectual disabilities. The Level 1 PASRR form for this resident, dated 02/09/2026, documented that the resident had an intellectual disability and that the form was required to be forwarded to the Regional Developmental Disabilities Administration (DDA) Intellectual Disability/Related Condition (ID/RC) PASRR team for follow-up before admission to a nursing facility. Despite this requirement, review of the resident’s electronic medical record showed no documentation that the Regional DDA ID/RC PASRR team had been contacted prior to the resident’s admission, and the resident was admitted with diagnoses including intellectual disabilities and disorders of psychological development. Interviews with facility staff confirmed a lack of awareness and implementation of the PASRR requirements. The Social Services Director stated they were unaware that the Level 1 PASRR needed to be forwarded to the Regional DDA ID/RC PASRR team before admission and reported that Admissions staff were responsible for reviewing PASRR information prior to admission. The Social Services Director also indicated they did not see a resident’s PASRR until after admission, once it was scanned into the electronic medical record. The Admissions staff member interviewed acknowledged responsibility for reviewing Level 1 PASRR forms before admission but stated they were unaware that this resident’s PASRR was required to be forwarded to the Regional DDA ID/RC PASRR team for review and determination related to the resident’s intellectual disability diagnosis.
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