Failure to Complete Required Level I PASARR for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a new Level I PASARR was completed within the required timeframe for a resident who remained in the facility for more than 30 days. 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 cognitive intactness. The care plan documented that the resident was receiving the psychotropic medication aripiprazole for PTSD and bipolar disorder, initiated and revised in late January 2026. The only PASRR available in the record was the preadmission PASRR from the hospital, which was null for serious mental illness and mental illness, and there was no evidence of a second Level I PASARR being completed after the resident had been in the facility for more than 30 days. Interviews with staff revealed gaps in responsibility and process for PASARR completion and review. The social services clerk reported working on discharge planning from admission and stated she did not handle PASARRs, while the regional LMSW explained that the facility had only recently received information to be able to submit PASARRs and that incorrect hospital PASRR data should be corrected immediately; however, no corrected PASRR was found for this resident. The MDS nurse stated he was told that social services reviewed PASARRs, that he did not check for Level II PASARRs, and that he had never seen a Level II from the hospital, acknowledging that an inaccurate Level I on admission could affect needed services. The admissions coordinator reported that PASARRs are reviewed prior to accepting a resident by herself and the central intake team, and that a corporate auditor reviews the PASARR and admission information. The facility’s PASRR policy stated that if a facility stay is longer than 30 days, a Level I screening must be performed within 40 days of admission, which was not done for this resident.
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