Failure to Accurately Complete PASARR Level I and Initiate Required Level II Evaluation
Penalty
Summary
The facility failed to ensure that a Level I Pre-admission Screening and Resident Review (PASARR I) was completed correctly for one resident, resulting in an omission of documented mental health diagnoses that should have triggered a Level II PASARR. Facility policy dated 8/29/25 required that a Level I PASRR be completed on potential admissions prior to admission, with a positive Level I screen leading to an in-depth Level II evaluation by the state-designated authority and a determination letter obtained prior to admission. The resident, who was initially admitted and later readmitted with multiple diagnoses including chronic post-traumatic stress disorder (PTSD) and joint replacement surgery aftercare, had Level I PASRR screenings dated 3/3/26 and 3/13/26 that did not document his PTSD and anxiety disorders. The resident’s medical record on 3/3/26 showed a medical diagnosis of chronic PTSD, yet as of 3/30/26 at 12:00 PM there was no documentation that a Level II PASARR had been completed, despite these qualifying mental health conditions. Staff later acknowledged that a Level II PASARR had only just been completed and sent for review, confirming that the required Level II process had not been initiated in a timely manner based on the resident’s documented diagnoses. This failure created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility.
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