Failure to Ensure Accurate Level I PASRR for Resident With Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure a complete and accurate Level I PASRR assessment on admission for one resident. The resident was admitted with diagnoses including generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and had a BIMS score of 15 indicating intact cognition. The resident’s care plan documented use of the psychotropic medication aripiprazole for PTSD and bipolar disorder, initiated and revised in late January 2026. However, the PASRR received from the hospital indicated “null” for serious mental illness and mental illness, meaning no psychiatric diagnoses were identified at the hospital level, despite the resident’s documented psychiatric conditions. During interviews, the social services clerk reported working on discharge planning from the beginning of admission but stated she did not handle PASRRs. A regional LMSW explained that the facility had recently obtained the ability to submit PASRRs electronically and stated that incorrect hospital PASRR data should be corrected immediately, acknowledging that the resident’s psychiatric diagnoses should have been identified and reviewed to determine if a Level II PASRR was needed. The MDS nurse stated he was told social services reviewed PASRRs and therefore did not check whether residents had a Level II, and that he had never seen a Level II from the hospital. The admissions coordinator reported that PASRRs are reviewed prior to accepting a resident by herself, central intake, and a corporate auditor, and that the Level I PASRR is usually the last document sent before admission. Despite this, the inaccurate Level I PASRR for this resident was not corrected on admission, contrary to the facility’s PASRR policy requiring Level I screening for all first-time applicants before admission or on the first day Medicaid reimbursement is requested.
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.