Failure to Obtain Required PASRR Level II Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to coordinate required PASRR evaluations for a resident with major mental illness in accordance with its own policy and federal guidance. The facility’s Resident Assessments PASRR Screening Coordination policy required that PASRR Level I and Level II screenings, when needed, be conducted prior to admission, and that Level II evaluation reports be used when conducting assessments and developing care plans. The State Operations Manual, Appendix PP, specified that a positive Level I screen requires an in-depth Level II evaluation by the state-designated authority prior to admission. Despite these requirements, the facility did not ensure that the appropriate PASRR process was completed. Resident #4 was admitted with multiple diagnoses, including COPD, Bipolar Disorder, and PTSD. The resident’s care plan documented that the resident met PASRR Level II determination secondary to serious mental illness diagnoses, including anxiety and bipolar disorder, and a long-term care stay. However, the medical record showed that a PASRR Level I screening was not completed until more than eight months after admission, and that this Level I identified major mental illnesses (depressive, anxiety, bipolar, and PTSD) and directed that the screening be forwarded to the state-designated authority for a PASRR Level II evaluation. As of the surveyor’s review, there was no documentation that a PASRR Level II evaluation had been completed, and the RNC confirmed that the facility did not have a PASRR Level II for this resident and should have had one.
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